[Remote] Senior Network Optimization Professional at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Bachelor’s Degree or Equivalent
3+ years of provider data management experience
2+ years of process creation or improvement experience
Strong knowledge of provider network operations tools, processes, and best practices
Ability to quickly learn new systems and processes
Ability to manage and prioritize multiple projects or priorities
Proficiency at achieving results within a highly matrixed organization
Proficient in SQL
Proficient in MS Office Applications including Teams, MS Word, PowerPoint, Outlook, and Excel
Excellent written and verbal communication skills
Experience in Network Adequacy (preferred)
Strong familiarity with Medicaid, Ohio Medicaid, and/or Ohio Medicaid NextGen program (preferred)
Proficiency in Microsoft Access and Sharepoint (preferred)
Proficiency in PowerBI (preferred)

Responsibilities

Drives network optimization and value through network contracting governance, process development, and data governance for Ohio Medicaid
Develops contracting requirements, internal reporting compliance processes, and supports data integrity as required in the Ohio Medicaid Provider Agreement
Supports network optimization and governance through the development of governance tools, processes, and policies for the Humana Healthy Horizons Ohio Network Optimization team
Works closely with internal partners to facilitate the creation of reporting and tools needed to meet regulatory requirements and to transition from an adequate to a fully optimized network
Reports to a Network Optimization Lead

Skills

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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