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Humana Gold Plus Integrated is seeking a Director of Provider Services to lead a team that is accountable for growing positive, long-term relationships with network Dual Special Needs (DNSP) providers to foster positive provider experiences, accurate and timely provider claims submissions, and high-quality care delivery among network providers, resulting in improved financial and quality performance. This senior market leader is responsible for ensuring collaboration across Medicare and Medicaid lines of business and will oversee a team of direct and indirect reports responsible for provider relations and training, claims education, provider engagement, and practice transformation.

The Director is responsible for setting strategic direction for these accountable business functions, representing the team at meetings with the state, CMS, and/or key provider groups, ensuring that all provider services functions meet contractual requirements and reports are completed timely and accurately.

The Director of Provider Services requires an in-depth understanding of how organization capabilities interrelate across the team, Illinois Medicare and Medicaid markets, and the enterprise. This is a dynamic role requiring strong leadership experience, critical thinking/problem solving skills, and a strategic mindset. This position is dedicated to the Illinois Medicaid plan.

The Director of Provider Services responsibilities include:

• Set strategic direction for and oversee key business functions, including provider relations and training, claims analysis and education, provider quality and value-based payment performance, and practice transformation.
• Build and support the development and growth of positive, long-term relationships with network DSNP providers, including but not limited to primary care providers, hospitals, rural health clinics, human services districts, federally qualified health centers, behavioral health providers, Non-traditional Medicaid Providers, long-term care providers and healthcare systems to maintain service support excellence and improve financial and quality performance within the contracted working relationship with the health plan.
• Ensure adequate provider services staff are available to efficiently address and resolve provider issues. Regularly review data, such as claims denial/rework data and trends, call center data, and provider performance data to monitor team performance and guide strategic improvements to provider relationships and performance.
• Provide Illinois market oversight and governance of provider audits, compliance, provider surveys, provider service and relations, credentialing, contract management systems, and practice transformation.
• Ensure team’s compliance with Illinois Managed Care Contractual requirements for provider relations, such as claims dispute resolution within specified timeframes.
• Work closely with enterprise teams on claims processing, reporting, contracting/credentialing, network adequacy, provider dispute resolution issues, and provider performance tracking and tool enhancements.
• Guide the Provider Services Advisor to plan and deliver regular and ad hoc provider communications and provider training and education strategy.
• Coordination of communications with Subcontractors and other providers.
• Drive performance, develop operational policies and procedures to align with the provider services model and execute on strategic initiatives within the provider network.
• Represent Humana at meetings with the Illinois Department of Healthcare and Family Services Dual Eligible Special Needs Plan.
• Participate in, and travel to if needed, key provider meetings and provider association meetings.
• Conduct regular performance evaluation of employees and provide ongoing feedback and coaching as necessary to achieve service, quality, and production goals.
• Identify and support professional development for direct and indirect reports to drive exceptional associate engagement and performance.
• Set and monitor team key performance indicators.

Use your skills to make an impact

Required Qualifications

• Must live in or be willing to relocate to the State of Illinois and be able to travel throughout Illinois.
• Bachelor's degree.
• 5+ years in provider relationship management, provider education, provider issue resolution, and provider value-based performance improvement.
• 5+ years of experience working with DSNP and Medicare programs.
• 2+ years of project leadership experience.
• 5+ years of direct management experience.
• Experience with data analysis, understanding, communicating, and reporting on operational trends and gaps.
• Knowledge of Medicaid and Medicare regulatory requirements.
• Intermediate to advanced knowledge of Microsoft Suite applications, specifically Word, Excel, and PowerPoint.
• This role is a part of Humana’s Driver Safety program and therefore requires an individual to have a valid state driver’s license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,000 limits.

Preferred Qualifications

• Master’s degree.
• Experience with credentialing and contract management systems
• Working knowledge of managed care health plan and provider operations.

Work at Home Requirements

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Additional Information

• Direct Reports: Up to five associates.
• Workstyle: Hybrid Home; must live in the State of Illinois.
• Travel: Up to 20% travel in the field across the state of Illinois.
• Core Workdays & Hours: Typically, 8-5 pm Monday – Friday; Central Standard Time (CST) with flexible scheduling (i.e. occasional nights and weekends).
• Benefits: Benefits are effective on day 1. Full time Associates enjoy competitive pay and a comprehensive benefits package that includes; 401k, Medical, Dental, Vision and a variety of supplemental insurances, tuition assistance and much more.....

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$138,900 - $191,000 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.