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The Associate Director Operations oversees the plan’s strategic opportunity for growth, audit/survey analysis, action plan oversight, implementation and coordination, provider services and network development and required credentialing processes and coordination. They coordinate workforce development initiatives and work collaboratively with Humana business area leads, other contracted MCO’s and the Department as prescribed. They maintain provider relations to support customer service activities through data integrity management and gathering of provider claims data needed for service operations. Responsible for the retention of the plan’s network of providers, creating a qualified, serviceable, and comprehensive network. This is a collaborative role requiring critical thinking skills, independence, leadership, a strategic mindset, and attention to detail.

This position requires residence in South Carolina and will include attending onsite meetings in Columbia at least one time monthly.

               

• Work closely with Data Management teams on enrollment, claims processing, encounter submission, resolution issues, and provider performance tool enhancements.

• Supports the development and growth of positive, long-term relationships with physicians, providers and healthcare systems in order to maintain and improve financial and quality performance within the contracted working relationship with the health plan.

• Provides market oversight and governance of provider audits, provider surveys, provider service and relations, credentialing, and contract management systems. Provides oversight and governance of the executed processes for intake and management of provider perceived service failures.

• Work closely with Product Teams to ensure new developments align with provider expectations.

• Drives performance 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 team in alignment with market strategies and initiatives.

• Reviews, assesses and develops outreach strategies based on available and appropriate data; and provides consistent communication of goals/outcomes.

• Partners with marketing to develop outreach collateral and strategies to be used uniformly throughout the market.

• Provides market oversight and governance of the management of provider data for the health plan including but not limited to demographics, rates, and contract intent.

• 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 Relations outreach activities.

• Dedicated Full time responsibility to the South Carolina Medicaid plan

Use your skills to make an impact
 

Required Qualifications

• Bachelor's Degree and/or equivalent 10 years progressive combination contracting, claims, credentialing, and operations experience for a national health plan.

• Minimum 2 years of solid leadership/management experience including supervisory and teambuilding

• Strong financial acumen with proficiency in analyzing and interpreting trends (Quickbase, Excel)

Workstyle: Remote work at home

Location: South Carolina

Schedule: Monday through Friday 8:00 AM - 5:00 PM Eastern

Travel: Onsite meetings in Columbia at least one time monthly

Work at Home Guidance 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 recommended; wireless, wired cable or DSL connection is suggested

• Satellite, cellular and microwave connection can be used only if approved by leadership

• Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

• Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.

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