[Remote] Senior Provider Relations Professional at Humana

Michigan, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Medicaid, InsuranceIndustries

Requirements

3+ years of health care or managed care experience working with providers (e.g., provider relations, claims education)
Experience with Michigan Medicaid
Knowledge of Microsoft Office applications
Demonstrated ability to manage multiple projects and meet deadlines
Exceptional relationship management skills
Experience handling escalated or highly visible provider complaints/issues to resolution
Understanding of health insurance claims and ability to analyze data to resolve provider service issues
Excellent written and verbal communication skills
Proficiency in analyzing, understanding, and communicating complex issues
Exceptional time management and ability to manage multiple priorities in a fast-paced environment
Located in or willing to relocate to the Metro Detroit area
Travel 3-5 days a week – Metro Detroit Area
Must have a valid driver’s license with reliable transportation and the ability to travel within the state, as required
Proof of personal vehicle liability insurance with at least 100,000/300,000/100,000 limits (part of Humana's Driver safety program)
Preferred Qualifications
Bachelor’s Degree
Experience working for or with key provider types (primary care, FQHCs, hospitals, nursing facilities, and/or HCBS and LTSS providers)
Experience with claims systems, adjudication, submission processes, coding, and/or dispute resolution
Experience with service coordination, prior authorizations, and other health plan processes

Responsibilities

Foster positive, long-term relationships with network providers in Michigan’s Humana Medicaid Program
Manage onboarding and orientations for new providers to Humana’s network
Conduct ongoing education and training to support network providers in self-service functions (e.g., eligibility confirmation, claims submission and payment) using available tools
Schedule, prepare, and facilitate Joint Operating Committee or other provider meetings, sometimes in partnership with other teams
Ensure prompt resolution of provider inquiries, concerns, or problems, including those related to claims payment, prior authorizations, referrals, and state or Commissioner of Insurance inquiries
Create and/or deliver trainings and educational materials for Humana Michigan Medicaid providers on processes, procedures, and website content
Participate and/or speak at Town Halls, webinars, or other forums to communicate policy or programmatic updates
Ensure compliance with Michigan managed care contractual requirements for provider relations (e.g., claims dispute resolution within specified timeframes)
Schedule, prepare, and complete on-site provider location visits to nurture relationships; attend association conferences as necessary
Obtain and relay accurate required credentialing documents to the credentialing team from the provider

Skills

Key technologies and capabilities for this role

Provider RelationsMedicaid Program ManagementProvider OnboardingClaims ProcessingPrior AuthorizationsProvider TrainingJoint Operating CommitteeHealth Plan OperationsCritical ThinkingProblem SolvingInterpersonal Skills

Questions & Answers

Common questions about this position

What experience is required for the Senior Provider Relations Professional role?

Candidates need 3+ years of health care or managed care experience working with providers, such as provider relations or claims education, plus experience with Michigan Medicaid.

Is this a remote position or does it require on-site work?

The role requires scheduling, preparing, and completing on-site provider location visits to nurture relationships, though day-to-day work details are not fully specified.

What key skills are needed for this position?

Essential skills include critical thinking/problem solving, exceptional relationship management, excellent written and verbal communication, proficiency in analyzing data, and managing multiple projects while meeting deadlines.

What is the salary or compensation for this role?

This information is not specified in the job description.

What makes a strong candidate for this Senior Provider Relations Professional position?

Strong candidates will have experience handling escalated provider issues, knowledge of health insurance claims, Michigan Medicaid expertise, and skills in relationship management, communication, and data analysis to resolve complex issues.

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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