Humana

Network Optimization Principal

Michigan, United States

Not SpecifiedCompensation
Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
HealthcareIndustries

Network Optimization Principal

Employment Type: Full-time

Position Overview

The Network Optimization Principal oversees various efforts involving highly complex data analysis and consultation projects/contracts. This role provides strategic advice and guidance to functional team(s) and requires broad, advanced technical experience.

Role Overview

The Network Optimization Principal oversees the strategic development and maintenance of the Michigan HIDE SNP plan provider network. This senior-level strategist is responsible for driving network optimization and value, while also ensuring compliance with network requirements in the Michigan Managed Care Contract. The Principal will:

  • Analyze provider network performance to inform contracting and terminations.
  • Partner with the Provider Relations team to understand and address network operational issues.
  • 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 Operations Officer.

Position Responsibilities

  • Develop and implement network strategies to ensure access, adequacy, and high-value care aligned with organizational goals.
  • Maintain and update the network development plan annually.
  • Serve as subject matter expert on Michigan network standards, compliance, and provider crosswalk/mapping to ensure accurate state data submissions.
  • Identify and address Medicaid network adequacy risks and target provider recruitment to close gaps.
  • Oversee ad-hoc contracting, value-added and in-lieu-of service assessments, and provider data accuracy, coordinating with relevant departments.
  • Ensure timely state-required submissions for incurable gaps and terminations, and monitor network adequacy impacts from provider terminations.
  • Manage member and provider communications, maintain tracking systems, and oversee approvals for non-standard FFS or VBP rate requests.
  • Develop strategies and governance for Michigan value-based payment (VBP), review new arrangements, and pursue contract renegotiation to address trends.
  • Oversee VBP model management, monitor performance against KPIs, ensure compliance, and collaborate with leadership and cross-functional teams to drive improvements and advance strategic initiatives.

Required Qualifications

  • Bachelor’s Degree or equivalent experience of 10 years.
  • 6+ years’ experience working with a managed care organization or as a consultant in a network/contract management role (e.g., contracting, provider services).
  • 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.

Preferred Qualifications

  • Master’s Degree.
  • Experience with the Michigan Medicaid/Dual, including network adequacy requirements and standards for provider relations compliance.
  • Experience building teams from the ground up in a fast-paced implementation environment.

Additional Information

Work-At-Home Requirements

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 required.
  • A wireless, wired cable or DSL connection is required.
  • Satellite, cellular and microwave connection can be used only if approved by leadership.
  • Employees who live and work from home must adhere to these requirements.

Skills

Data Analysis
Network Optimization
Contracting
Provider Network Management
Value-Based Payment Strategy
Compliance
Strategic Planning
Problem-Solving
Leadership

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters
1961Year Founded
IPOCompany Stage
Social Impact, HealthcareIndustries
10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.
Rising medical costs and tightening Medicare reimbursements may strain financial performance.
Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.
The company emphasizes inclusivity, offering free language interpreter services for accessibility.
Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.
The company is the first insurer to cover TMS therapy for adolescent depression.
Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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