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THIS POSITION IS DEDICATED TO NORTH CAROLINA MEDICAID PLAN AND THE IDEAL CANDIDATE MUST RESIDE IN NORTH CAROLINA.

The North Carolina Medicaid Provider Services Director leads a team that is accountable for growing positive, long-term relationships with network providers to foster positive provider experiences, accurate and timely provider claims payment, and high-quality care delivery among network providers, resulting in improved financial and quality performance. This senior market leader will oversee a team of direct and indirect reports responsible for provider relations and training, claims education, provider engagement, and practice transformation. They are responsible for setting strategic direction for these accountable business functions, representing the team at meetings with the state and/or key provider groups, and overseeing that all provider services functions meet contractual requirements and state reports are completed timely and accurately. The Provider Services Director requires an in-depth understanding of how organizational capabilities interrelate across the team, North Carolina market, and the enterprise. This is a dynamic role requiring strong leadership experience, critical thinking/problem solving skills, and a strategic mindset.

Key Role Objectives 

• 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. 

• Builds and supports the development and growth of positive, long-term relationships with network providers, including but not limited to primary care providers, hospitals, rural health clinics, human services districts, federally qualified health centers, behavioral health providers, and 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. 

• 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. 

• Provides North Carolina 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 North Carolina’s 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. 

• Understand Humana’s interoperability capabilities, drive provider recruitment strategy and engage in provider recruitment calls. 

• Guide the Provider Services Advisor to plan and deliver regular and ad hoc provider communications and provider training and education strategy 

• Drive performance and develops operational policies and procedures to align with the provider services model and executes strategic initiatives within the provider network. 

• 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 

• Represent Humana at North Carolina Medicaid meetings  

• Participate in, and travel to if needed, key provider meetings and provider association meetings 

Use your skills to make an impact
 

Required Qualifications 

• Must reside in North Carolina

• Bachelor's degree 

• 8+ years in provider relationship management, provider education, provider issue resolution, and provider value-based performance improvement  

• 2+ years of project leadership experience. 

• 7+ years of management experience. 

• Working knowledge of managed care health plan and provider operations 

• Experience working with providers in North Carolina

• Experience with data analysis, understanding, communicating, and reporting on operational trends and gaps. 

• Knowledge of Medicaid regulatory requirements. 

• Intermediate knowledge of Microsoft Suite applications, specifically Word, Exce