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The Principal, Network Optimization oversees the strategic development and maintenance of SC Medicaid and Dual Special Needs Plan’s provider network. This senior-level strategist is responsible for driving network optimization and value, while also ensuring compliance with network requirements in the SC Managed Care Contract. The Principal will analyze provider network performance to inform contracting and terminations, partner with the Provider Relations/Engagement team to understand and address network operational issues, and advise on network composition, and value-based payment strategy. This is a collaborative role requiring critical thinking and problem-solving skills, independence, leadership, a strategic mindset, and attention to detail. This position reports to the plan’s Chief Operating Officer.

· Define & execute network development strategy that promotes access, adequacy, and drives high value care delivery in alignment with financial, operational and clinical goals.

· Maintain annual and ad hoc updates to network development plan

· Subject Matter Expert (SME) on SC contractual requirement for network standards and penalties for noncompliance.

· Identify areas of risk with Medicaid NetAd reporting and strategize network time & distance, provider-to-enrollee ratio, and/or timely access gap closures by targeting providers for recruitment to Humana network and monitoring progress.

· Subject Matter Expert (SME) on provider crosswalk/mapping from Humana’s data to state file and ensure accuracy on data submissions to the state agency.

· Oversee ad hoc contracting/re-contracting campaigns for new or expanded services.

· Collaborate with clinical and utilization management (UM) to identify access to care issues that include timely access standards, geographic barriers, close panel limitations, operational issues (i.e.: Problems with claims payment, staffing, rates), and member-specific barriers.

· Manage network assessment and build for value-added benefit and in-lieu of services.

· Root cause load inaccuracies that result in provider not reflecting correctly on state provider files and/or directory. Relay to appropriate department to address issue.

· Ensure required submissions to state agency for incurable gaps and terminations.

· Monitor terminations to account for termination impact and adequacy fluctuations.

· Oversee required communication processes to notify members & providers.

· Develop tracking system for transparency

· Sets strategy and identify providers for participation in value-based payment (VBP) programs for SC according to contract requirements

· Lead routine value-based payment (VBP) governance forum to manage VBP strategy execution and review new VBP deals; manage approvals for non-standard FFS or VBP rate requests.

· Identify trend-bender opportunities through contract renegotiation and VBP.

· Provides market oversight and governance of the management of SC value-based payment models.

· Monitor performance against key performance indicators (KPIs) and ensure compliance with contractual commitments and requirements. Partner with health plan leadership to improve KPI performance and ensure contractual compliance.

· Participates in operating meetings, as needed, for key provider relationships to facilitate strategic initiatives and improved performance.

· Works collaboratively with Chief Operating Officer, Provider Services Director, health plan finance, corporate Network Operations, clinical and quality teams to achieve strategic goals and priorities.

Use your skills to make an impact
 

Required Qualifications

Bachelor’s Degree

· 6+ years’ experience working with a managed care organization or as a consultant in a network/contract management role, such as contracting, provider services, etc.

· 2+ years of experience in provider network development, including contracting, network operations, and/or network maintenance

· 4+ years of experience in value-based contracting models

· 2+ years of experience in data analysis

· Proficiency with a wide range of physician/facility/ancillary contract reimbursement methodologies

· Prior leadership and management experience

· Ability to manage multiple priorities in a fast-paced environment

· Experience working in a matrixed organization and influencing change and direction

· Must be passionate about contributing to an organization focused on continuously improving consumer experiences

· The applicant must be located in or willing to relocate to SC– (if market has local Humana office) position may be based at our office in[city] or remote within the state.

Preferred Qualifications