Network Optimization Principal

Employment Type: Full-time

Position Overview

Humana Gold Plus Integrated is seeking a highly strategic and detail-oriented Network Optimization Principal to lead the development and maintenance of the Illinois Medicaid and LTSS plan’s provider network. This senior-level role is responsible for driving network optimization and value, ensuring compliance with Illinois Managed Care Contract network requirements. The Network Optimization Principal will analyze provider network performance, inform contracting and termination decisions, partner with Provider Relations to address operational issues, and advise on network composition and value-based payment strategy. This is a collaborative role requiring critical thinking, problem-solving, independence, leadership, a strategic mindset, and attention to detail. This position reports to the plan’s Chief Operating Officer.

Responsibilities

• Define and execute network development strategy to promote access, adequacy, and high-value care delivery, aligning with financial, operational, and clinical goals.
• Maintain annual and ad hoc updates to the network development plan.
• Serve as a Subject Matter Expert (SME) on Illinois contractual requirements for network standards and penalties for non-compliance.
• Analyze internal and external data, as well as market intelligence.
• Monitor network adequacy data to recommend targeted contracting opportunities and support resolution processes for network terminations.
• Identify areas of risk in Medicaid NetAd reporting and strategize network time & distance, provider-to-enrollee ratios, and timely access gap closures by targeting providers for recruitment and monitoring progress.
• Serve as a Subject Matter Expert (SME) on provider crosswalk/mapping from Humana’s data to state files, ensuring accuracy in 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) teams to identify access-to-care issues, including timely access standards, geographic barriers, close panel limitations, operational issues (e.g., claims payment, staffing, rates), and member-specific barriers.
• Manage network assessment and build for value-added benefits and in-lieu-of services.
• Identify root causes for inaccuracies in provider data that affect state provider files and/or directories, and relay issues to the appropriate department for resolution.
• Ensure required submissions to the state agency for incurable gaps and terminations are completed.
• Monitor terminations to account for their impact on network adequacy.
• Oversee required communication processes to notify members and providers.
• Develop a tracking system for transparency.
• Manage approvals for non-standard Fee-for-Service (FFS) or Value-Based Payment (VBP) rate requests.
• Set strategy and identify providers for participation in VBP programs for Illinois according to contract requirements.
• Lead routine VBP governance forums to manage VBP strategy execution and review new VBP deals.
• Identify trend-bender opportunities through contract renegotiation and VBP.
• Provide market oversight and governance for the management of Illinois required VBP 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.
• Participate in operating meetings for key provider relationships to facilitate strategic initiatives and improved performance.
• Work collaboratively with the Chief Operating Officer, Provider Services Director, health plan finance, and clinical and quality teams to achieve strategic goals and priorities.

Requirements

• Must have... (Further qualifications to be added)

Company Information

• Company: Humana Gold Plus Integrated
• Mission: To put health first and foster a caring community.