The Provider Relations Representative (Provider Engagement Professional) is responsible for day-to-day front line relationship management of network providers in Humana's Healthy Horizons in Virginia Medicaid network. This role supports provider onboarding, training, education, and inquiry/issue support resolution. This role specifically supports long-term services and supports (LTSS) and home and community-based services (HCBS) providers and must be based in Virginia. The individual in this role should have critical thinking/problem solving skills, understanding of health plan operations, and strong interpersonal skills.
Serve as primary relationship manager with assigned LTSS and HCBS providers to ensure positive provider experience with Humana Healthy Horizons and promote network retention
Meet regularly, both in person and virtually, with assigned providers to conduct training and education, including, but not limited to, required annual trainings, periodic updates to and/or reviews of Humana policies and procedures, and Humana systems training and updates
Support newly assigned providers with onboarding, including hosting orientation session(s)
Respond to assigned provider inquiries and support prompt issue resolution, including, where necessary, collaboration with appropriate enterprise business teams (ex., claims payment, prior authorizations & referrals)
Work with internal resources and systems (e.g., claims, reimbursement, provider enrollment) to provide Exceptional Experience in all provider interactions
Create provider trainings based on provider feedback, trends in claims or process changes
Educate provider on location and content of all provider facing materials (Orientation, Provider Manual, Newsletter, Program Updates, Etc.)
Convene regular meetings with providers, including organizing agendas, materials, meeting minutes, other team members (clinical, provider engagement), to discuss key operational, clinical, and quality related topics
Educate on processes including claims submissions, recoupments, reconsiderations, authorizations, referrals, medical record management, Availity, Quality resources, and member resources
Communicate updates on Humana's policies and procedures and Cardinal Care programmatic updates
Coordinate regional provider townhalls and/or trainings
Attend Network Meetings/Conferences
Ensure compliance with all Virginia managed care contractual requirements for provider relations, such as timeframes for claims dispute resolution, provider complaints, provider inquiry response, etc
Must reside in Virginia (SW region includes, Lee, Wise, Washington and Galax)
Bachelors degree OR 1 - 5 years of Health care or managed care with Provider Contracting, Network Management or Provider Relations experience
Proven planning, preparation and presenting skills, with established knowledge of reimbursement and bonus methodologies
Demonstrated ability to manage multiple projects and meet deadlines
Preferred Qualifications
Master's Degree
Proficiency in analyzing and interpreting financial trends for health care costs, administrative expenses and quality/bonus performance
Comprehensive knowledge of Medicare policies, processes and procedures
Experience with Medicaid electronic visit verification (EVV)
Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
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.
$59,300 - $80,900 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
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.
