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Humana Healthy Horizons in Virginia is seeking a Director, Provider Engagement who will oversee the plan’s strategic provider services model, including direct reports responsible for Provider Relations, Provider Engagement and Network Development. The Director, Provider Engagement coordinates communication between Humana and its network providers and works collaboratively with Humana corporate and Virginia market business area leads, other contracted MCO’s and the Virginia Department of Medical Assistance Services (DMAS) as prescribed. They will maintain all provider services functions to meet regulatory requirements and support provider services activities through data integrity management, provider education, issue resolution, and gathering of provider claims data needed for service operations. The Director, Provider Engagement is responsible for the retention of the plan’s network of providers, creating a qualified, serviceable, and comprehensive network with a full array of service supports. This is a collaborative role requiring critical thinking/problem solving skills, cross functional alliances, independence, leadership, a strategic mindset, and attention to detail regarding how organizational capabilities interrelate across the function or segment.

• Builds and supports the development and growth of positive, long-term relationships with physicians, key provider groups, non-hospital facilities, rural health clinics, human services districts, federally qualified health centers and other healthcare systems in order to maintain service support excellence and improve financial and quality performance within the contracted working relationship with the health plan.
• Represents the scope of health plan/Provider relationship across such areas as financial performance, value-based payment incentive programs, quality and clinical management, population health, data sharing, claims payment/billing inquiry resolution, documentation, and coding, NCQA accreditation, HEDIS and STARs performance, operational improvements and other areas as they relate to provider performance, enrollee experience, market growth, provider experience and operational excellence.
• Provides Virginia market oversight and governance of provider audits, compliance, provider surveys, provider service and relations, credentialing, contract management systems, and practice transformation.
• Provides oversight and governance of the executed processes for intake and management of provider perceived service failures through regular review of provider complaints data and trends.
• Work closely with Shared Services and Data Management teams on claims processing, reporting, contracting/credentialing, network adequacy, provider dispute resolution issues, and provider performance tracking and tool enhancements.
• Work closely with internal and external SMEs to ensure new initiatives, bulletins, health plan advisories or plan changes align with the provider expectations and provider education plans.
• Drives performance, develops operational policies and procedures to align with the provider services model and executes on strategic initiatives within the provider network.
• In coordination with health system leadership, develops annual and quarterly strategic targeting objectives for provider relations and engagement teams in alignment with market strategies, initiatives, policies, and contractual obligations.
• Reviews, assesses, and develops provider outreach strategies based on available and appropriate data; and provides consistent communication of goals/outcomes.
• Partners with marketing to develop Virginia specific provider outreach collateral and strategies to be used uniformly throughout the market.
• Leads the development, implementation and execution on provider trainings, content development, provider webinars and regional education forums and other provider-related engagement activity.
• Coordinates and collaborates with a matrix team of provider service and contracting representatives to ensure that Humana processes are aligned with state contract and regulatory requirements.
• Ensures compliance with contractual requirements as it relates to the market network and directs process improvement to address network non-compliance, market strategy and initiatives.
• Collaborates weekly (or as needed) with health system leadership to discuss trends, business growth opportunities, obstacles to service line retention, and results from Provider Services outreach activities.
• Serves as the Lead for all provider-related internal/external committees and operational meetings to identify and discuss performance trends, interventions, and opportunities for improvement.

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Required Qualifications