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Humana Gold Plus Integrated is seeking a Network Optimization Principal who leads the strategic development and maintenance of Illinois Medicaid and LTSS plan’s provider network. This senior-level strategist is responsible for driving network optimization and value, while also ensuring compliance with network requirements in the Illinois Managed Care Contract.

The Network Optimization Principal will analyze provider network performance to inform contracting and terminations, partner with the Provider Relations team to understand and address network operational issues, and advise on network composition, and value-based payment strategy. This is a collaborative role requiring critical thinking and problem-solving skills, independence, leadership, a strategic mindset, and attention to detail. This position reports to the plan’s Chief Operating Officer.

The Network Optimization Principal responsibilities include:

Define & execute network development strategy that promotes access, adequacy, and drives high value care delivery in alignment with financial, operational and clinical goals.
Maintain annual and ad hoc updates to network development plan.
Subject Matter Expert (SME) on Illinois contractual requirement for network standards and penalties for noncompliance.
Analyze internal and external data, as well as market intelligence information.
Monitor network adequacy data to recommend targeted contracting opportunities and support resolution process in the event of network terminations.
Identify areas of risk with Medicaid NetAd reporting and strategize network time & distance, provider-to-enrollee ratio, and/or timely access gap closures by targeting providers for recruitment to Humana network and monitoring progress.
Subject Matter Expert (SME) on provider crosswalk/mapping from Humana’s data to state file and ensure accuracy on data submissions to the state agency.
Oversee ad hoc contracting/re-contracting campaigns for new or expanded services.
Collaborate with clinical and utilization management (UM) to identify access to care issues that include timely access standards, geographic barriers, close panel limitations, operational issues (IE Problems with claims payment, staffing, rates), and member-specific barriers.
Manage network assessment and build for value-added benefit and in-lieu of services.
Root cause load inaccuracies that result in provider not reflecting correctly on state provider files and/or directory. Relay to appropriate department to address issue.
Ensure required submissions to state agency for incurable gaps and terminations.
Monitor terminations to account for termination impact and adequacy fluctuations.
Oversee required communication processes to notify members & providers.
Develop tracking system for transparency.
Manage approvals for non-standard FFS or VBP rate request.
Sets strategy and identify providers for participation in value-based payment (VBP) programs for Illinois according to contract requirements.
Lead routine value-based payment (VBP) governance forum to manage VBP strategy execution and review new VBP deals.
Identify trend-bender opportunities through contract renegotiation and VBP.
Provides market oversight and governance of the management of Illinois required value-based payment models.
Monitor performance against key performance indicators (KPIs) and ensure compliance with contractual commitments and requirements. Partner with health plan leadership to improve KPI performance and ensure contractual compliance.
Participates in operating meetings for key provider relationships to facilitate strategic initiatives and improved performance.
Works collaboratively with Chief Operating Officer, Provider Services Director, health plan finance, and clinical and quality teams to achieve strategic goals and priorities.

Use your skills to make an impact

Required Qualifications

Must live in or be willing to relocate to the State of Illinois and be able to travel throughout Illinois as needed for role.
Bachelors degree.
6+ years of experience working with a managed care organization or as a consultant in a network/contract management role, such as contracting, provider services, etc.
2+ years of experience in provider network development, including contracting, network operations, and/or network maintenance.
4+ years of experience in value-based contracting models.
2+ years of experience in data analysis.
Proficiency with a wide range of physician/facility/ancillary contract reimbursement methodologies.
Prior leadership and management experience.
Ability to manage multiple priorities in a fast-paced environment.
Experience working in a matrixed organization and influencing change and direction.
Knowledge of Medicaid and Medicare regulatory requirements.
Intermediate to advanced knowledge of Microsoft Suite applications, specifically Word, Excel, and PowerPoint.
This role is a part of Humana’s Driver Safety program and therefore requires an individual to have a valid state driver’s license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,000 limits.

Preferred Qualifications

Master’s degree.
Experience with the Illinois Medicaid contract, including network adequacy requirements and standards for provider relations compliance.
Proficiency in Microsoft Access.
Experience building teams from the ground up in a fast-paced implementation environment.

Work at Home Requirements

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.
Associates 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 associates with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Additional Information

Direct Reports: Up to five associates.
Workstyle: Remote – work at home; must live in the State of Illinois.
Travel: Up to 20% travel in the field across the state of Illinois.
Core Workdays & Hours: Typically, 8-5 pm Monday – Friday; Central Standard Time (CST) with flexible scheduling (i.e. occasional nights and weekends).
Benefits: Benefits are effective on day 1. Full time Associates enjoy competitive pay and a comprehensive benefits package that includes 401k, Medical, Dental, Vision and a variety of supplemental insurances, tuition assistance and much more.....

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

Travel: While this is a remote position, occasional travel to Humanas offices for training or meetings may be required.

Scheduled Weekly Hours

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$126,300 - $173,700 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.