Senior Network Program Specialist - Remote

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

Jobs related to managing provider networks that support client base. This includes hospital, physician, dental, and pharmaceutical networks. Examples include provider relations activities, analyzing provider performance, creating provider reimbursement arrangements, and credentialing activities.

Positions in this function are responsible for the successful program design, compliance with network requirements, network assessment and selection, and program/product implementation.  This includes enterprise-wide Clinically Integrated Network teams that focus on specific clinical area Lines of Service (e.g., Cardiology, Women's Health, Oncology, etc.) to improve the quality and affordability through improvements in appropriateness and effectiveness.  May perform network analysis and strategy development and implementation. Obtains data, verifies validity of data, and analyzes data as required. Analyzes network availability and access.

May make recommendations regarding use, expansion, selection of networks for various products based on that analysis.

• Analyzes and investigates
• Provides explanations and interpretations within area of expertise

Job Scope and Guidelines

• Uses pertinent data and facts to identify and solve a range of problems within area of expertise
• Investigates non-standard requests and problems, with some assistance from others
• Works exclusively within a specific knowledge area
• Prioritizes and organizes own work to meet deadlines
• Provides explanations and information to others on topics within area of expertise

You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

Primary Responsibilities:

• NPM_Review/Analyze/Validate/Support Network and Provider Performance Data
  • Review employer group/health plan expectations (e.g., commercial; government) in order to determine the potential impact to employer group/health plan membership
  • Gather data from relevant sources in order to respond to stakeholders' requests (e.g., employer groups; internal teams)
  • Analyze network and/or provider performance along key indicators (e.g., compliance with regulatory audits; financial performance; Benefit Cost Ratio; risk adjustment scores; prevalence rates; Unit Cost Reduction Trend) in order to determine which programs to implement and/or modify
  • Research competitor and external information regarding key network characteristics and contracting strategies in order to develop products and programs
  • Ensure relevant contract and demographic information is loaded into the applicable platform in order to support analysis and review
  • Review and/or analyze member/provider population information (e.g., cultural information; demographics; geographic coverage) in order to determine potential network gaps in care and risk adjustment indicator opportunities
  • Implement new rates with contracted providers based on provider performance
  • Validate network data for programs (e.g., transparency program)
  • Develop metrics and create performance reports for pay-for-performance programs (e.g., PBC; PCPI)
• NPM_Support/Develop/Drive Effective Network Programs
  • Determine performance metrics and programs to apply to specific providers based on competitive data, internal data (e.g., provider improvement opportunities) and applicable legal and regulatory requirements
  • Provide guidance to internal stakeholders regarding administration of contracts (e.g., contract language; coding) and advocacy. -Identify needs and create infrastructure and parameters for programs/networks/contracts (e.g., contract language; clinical quality initiatives; inter