Provider Optimization Professional
3.
6 Full-time 4 hours ago Full Job Description The Provider Optimization Professional is responsible for day-to-day back-end relationships and serves as liaison with network contractors, provider relations, clinical/quality team, contract management and shared services.
Will ensure prompt resolution of provider inquiries, concerns, problems or disputes, including those associated with claims payment, prior authorizations, referrals, and administrative issues to improve financial and quality performance.
The Provider Optimization Professional collaborates with the Provider Communications/Provider Education/Provider Relations/Engagement teams to ensure prompt and accurate provider claims processing of original claims, resubmissions, and overall adjudication of claims.
Additionally, the Provider Optimization Professional manage claims operations that involve member contact, investigation, and settlement of claims for and against the organization, and carry out Humana - s proactive approach to minimize claims denials through education and training.
The Provider Optimization Professional represents the scope of health plan/provider relationship across such areas as financial performance, incentive programs, quality and clinical management, population health, data sharing, connectivity, documentation, coding, and HEDIS performance.
Will also be responsible for project managing special projects/initiatives, system configuration and trend tracking/monitoring.
The individual in this role must exercise independent judgement and work under minimal supervision.
Responsibilities Key Role Objectives Functions as a project manager for provider issue resolution Identifies problems, provide solutions, and resolves promptly based on complaints, changes in contract language, reporting and trending Ensures prompt resolution of provider inquiries, concerns, problems or disputes, including those associated with claims payment, prior authorizations, referrals, and administrative issues, as well as appropriate education about participation in Humana - s South Carolina Medicaid plan Proactively monitors all claim and network operational trends and remediation Executes on Humana - s South Carolina provider network development strategies to ensure a sufficient network for meeting the health care needs of Humana - s South Carolina Medicaid plan members.
Assists with provider data validation efforts Develops strategic project plan and implements appropriate actions related to all access and availability surveys Market representative for reviewing all provider documentation (i.
e.
, P&P - s, Provider Manuals, Provider Resource Guide, Provider Billing Guide, etc.
) Assists with development and deployment of the quarterly Provider Newsletter Creates and monitors process for tracking of network compliance (i.
e.
, required provider trainings) Key decision maker on network optimization meetings (i.
e.
, PCP attribution, member disenrollment, etc.
) Coordinates channels of communication between Humana and its network providers Liaison between network shared services (i.
e.
, credentialing) and providers Gather PCMH and hospital incentive information for service fund Works with internal corporate partners to ensure cross-department communication and resolution of provider - s issues.
Responsible for scheduling and leading collaborative meetings with clinical, quality, community engagement, and provider/member experience teams Coordinates with Provider Call Center/Grievance & Appeals Department to review data, trends, and address provider issues Coordinates with Quality Department on provider support related to quality metrics, integration of care and opportunities for practice improvements Develops and implements operational policies and procedures to optimize the provider network Identifies critical issues, presents and proposes resolution for review and implements interventions Represents the scope of health plan/provider relationships across areas such as financial performance, incentive programs, quality and clinical management, population health, data sharing, connectivity, documentation and coding, HEDIS/STARS performance and operational improvements Works with internal resources and systems (i.
e.
, claims, reimbursement, provider enrollment) to provide the Perfect Experience in all provider interactions with Humana - s South Carolina Medicaid plan, remembering that the goal is always one call resolution Ensures compliance with South Carolina - s managed care contractual requirements for provider relations, such as claims dispute resolution within specified timeframes Manages confidential client information with discretion and good judgment in accordance with Company policies Required Qualifications - High school diploma or equivalent 4 or more years of progressive experience in managed care operations and provider relations Experience working with or in health care administration setting Exceptional relationship management skills Excellent written and verbal communication skills Proficient in analyzing, understanding, and communicating complex issues Thorough understanding of managed care contracts, including contract language and reimbursement Exceptional time management and ability to manage multiple priorities in a fast-paced environment Knowledge of Microsoft Office applications Proficient in analyzing and interpreting financial trends for health care costs, administrative expenses, and quality/bonus performance Preferred Qualifications Bachelor - s Degree Experience with South Carolina Medicaid Experience working with facilities and ancillary providers, and/or FQHCs is strongly desired Experience with claims systems, adjudication, submission processes, coding, and/or dispute resolution Additional Information Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters.
Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.
Every associate and contractor who work inside a Humana facility or in the field, regardless of vaccination status, must complete a daily health screening questionnaire.
WAH requirements:
Must have the ability to provide a high-speed DSL or cable modem for a home office.
Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.
Scheduled Weekly Hours 40 Not Specified 0.
Estimated Salary: $20 to $28 per hour based on qualifications.
6 Full-time 4 hours ago Full Job Description The Provider Optimization Professional is responsible for day-to-day back-end relationships and serves as liaison with network contractors, provider relations, clinical/quality team, contract management and shared services.
Will ensure prompt resolution of provider inquiries, concerns, problems or disputes, including those associated with claims payment, prior authorizations, referrals, and administrative issues to improve financial and quality performance.
The Provider Optimization Professional collaborates with the Provider Communications/Provider Education/Provider Relations/Engagement teams to ensure prompt and accurate provider claims processing of original claims, resubmissions, and overall adjudication of claims.
Additionally, the Provider Optimization Professional manage claims operations that involve member contact, investigation, and settlement of claims for and against the organization, and carry out Humana - s proactive approach to minimize claims denials through education and training.
The Provider Optimization Professional represents the scope of health plan/provider relationship across such areas as financial performance, incentive programs, quality and clinical management, population health, data sharing, connectivity, documentation, coding, and HEDIS performance.
Will also be responsible for project managing special projects/initiatives, system configuration and trend tracking/monitoring.
The individual in this role must exercise independent judgement and work under minimal supervision.
Responsibilities Key Role Objectives Functions as a project manager for provider issue resolution Identifies problems, provide solutions, and resolves promptly based on complaints, changes in contract language, reporting and trending Ensures prompt resolution of provider inquiries, concerns, problems or disputes, including those associated with claims payment, prior authorizations, referrals, and administrative issues, as well as appropriate education about participation in Humana - s South Carolina Medicaid plan Proactively monitors all claim and network operational trends and remediation Executes on Humana - s South Carolina provider network development strategies to ensure a sufficient network for meeting the health care needs of Humana - s South Carolina Medicaid plan members.
Assists with provider data validation efforts Develops strategic project plan and implements appropriate actions related to all access and availability surveys Market representative for reviewing all provider documentation (i.
e.
, P&P - s, Provider Manuals, Provider Resource Guide, Provider Billing Guide, etc.
) Assists with development and deployment of the quarterly Provider Newsletter Creates and monitors process for tracking of network compliance (i.
e.
, required provider trainings) Key decision maker on network optimization meetings (i.
e.
, PCP attribution, member disenrollment, etc.
) Coordinates channels of communication between Humana and its network providers Liaison between network shared services (i.
e.
, credentialing) and providers Gather PCMH and hospital incentive information for service fund Works with internal corporate partners to ensure cross-department communication and resolution of provider - s issues.
Responsible for scheduling and leading collaborative meetings with clinical, quality, community engagement, and provider/member experience teams Coordinates with Provider Call Center/Grievance & Appeals Department to review data, trends, and address provider issues Coordinates with Quality Department on provider support related to quality metrics, integration of care and opportunities for practice improvements Develops and implements operational policies and procedures to optimize the provider network Identifies critical issues, presents and proposes resolution for review and implements interventions Represents the scope of health plan/provider relationships across areas such as financial performance, incentive programs, quality and clinical management, population health, data sharing, connectivity, documentation and coding, HEDIS/STARS performance and operational improvements Works with internal resources and systems (i.
e.
, claims, reimbursement, provider enrollment) to provide the Perfect Experience in all provider interactions with Humana - s South Carolina Medicaid plan, remembering that the goal is always one call resolution Ensures compliance with South Carolina - s managed care contractual requirements for provider relations, such as claims dispute resolution within specified timeframes Manages confidential client information with discretion and good judgment in accordance with Company policies Required Qualifications - High school diploma or equivalent 4 or more years of progressive experience in managed care operations and provider relations Experience working with or in health care administration setting Exceptional relationship management skills Excellent written and verbal communication skills Proficient in analyzing, understanding, and communicating complex issues Thorough understanding of managed care contracts, including contract language and reimbursement Exceptional time management and ability to manage multiple priorities in a fast-paced environment Knowledge of Microsoft Office applications Proficient in analyzing and interpreting financial trends for health care costs, administrative expenses, and quality/bonus performance Preferred Qualifications Bachelor - s Degree Experience with South Carolina Medicaid Experience working with facilities and ancillary providers, and/or FQHCs is strongly desired Experience with claims systems, adjudication, submission processes, coding, and/or dispute resolution Additional Information Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters.
Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.
Every associate and contractor who work inside a Humana facility or in the field, regardless of vaccination status, must complete a daily health screening questionnaire.
WAH requirements:
Must have the ability to provide a high-speed DSL or cable modem for a home office.
Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.
Scheduled Weekly Hours 40 Not Specified 0.
Estimated Salary: $20 to $28 per hour based on qualifications.
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