Be part of the Provider Contracting world at Humana where you will help maintain a competitive network for our members.
Humana’s National Contracting and Network Development teams are positioned within the Health and Well-Being Services segment and closely aligned with Provider Development and Engagement leaders. This alignment creates a “one-team” approach focused on the goals of the Integrated Care Model. National Contracting is led by a Corporate Vice President and includes more than 500 associates nationally. There are three Regional Vice Presidents (RVP’s) who have responsibility for approximately 25 defined market geographies led by Field Vice Presidents (FVP’s).
The Field Vice President, Network Development is responsible for developing and driving innovative network design and risk contracting strategies to ensure Humana builds a quality provider network to meet the health care needs of our members. In Washington and Oregon, this role is focused exclusively on our Medicare members.
This FVP role serves as the primary liaison with the Plan’s contracted vendors in the field, and is responsible for managing relationships with all Internal entities (administrative services, claims processing, member services, enrollment, facilities/mailroom, and operational quality assurance), ensuring a high level of provider satisfaction.
Key Role Objectives
Develop comprehensive knowledge of the Health & Well-being organization strategy, capabilities, best practices and tools and the current state (deployment) of the Integrated Care strategy within the Senior Products (Medicare) segment.
Identifies and contracts with primary care physicians, specialty physicians and ancillary service providers. Ensures adequate coverage of primary care, specialty and ancillary services for Humana to meet both regulatory and sales support needs.
Works closely with the Market President, Provider Development leaders and the Regional Medical Director to ensure physician alignment programs are increasing aligned with the Integrated Care Model and developed to achieve competitive advantage in the market.
Represents Humana as a progressive thought leader on Health Care Reform initiatives and our approach to improving our health care system.
Drives improvement in provider and member satisfaction results by partnering with Medical Management, Marketing, Finance, and Operations organization staff.
Identifies opportunities for service improvements and cost savings. Manages the execution of cost containment and medical expenses across all products to ensure meeting budget targets. Ensures appropriate economic terms and quality measures, as part of contract negotiation.
Works closely with sales and marketing to ensure the provider network is sufficient to support the planned sales process execution.
Offers orientation for providers within the Humana’s network. Assists providers in understanding contractual business terms and plan requirements; manages provider relationships, identifying opportunities for improvement in provider education and communication.
Recommends changes in Plan procedures and systems to meet providers’ needs. Serves as a resource for complex claims payment issues. Works to lead the market and its representatives in resolving claims payment issues to improve provider satisfaction.
Develops, manages, and maintains contractual relationships with hospitals, skilled nursing facilities, and supports nationally contracted ancillary services (lab, pharmacy, home care, radiology ) on an “as needed” basis.
Ensures that provider data is loaded accurately and in a timely manner, including but not limited to the Provider Database and Provider Directory. Maintains contract summaries and provides staff with relevant information for contract management and for accessing contracted services.
Leads as appropriate, the development of out-of-network arrangements for unplanned services such as hospital admissions and emergency specialty care; assists in the transition of out-of-network relationships into contracted status as appropriate.
Participates in network Quality Improvement program and initiatives, and acts as a resource for new provider credentialing and re-credentialing issues.
Ensures successful execution of attracting, developing, motivating, and retaining departmental talent.
Builds Human Capital: You deliver current, direct, complete and actionable feedback to associates to support continuous learning and growth; while ensuring that diverse perspectives are widely held, modeled and promoted. By selecting, deploying, developing and rewarding diverse talent, you are able to foster Humana’s strategy and meet business requirements.
Sees the Whole System: You understand and effectively influence the multiple processes and components of the organization, its stakeholders and environment; acting in ways that optimize business performance.
Leadership: You inspire extraordinary results by: engaging associates, valuing diversity and shaping culture to support a high performance environment.
Champions the Customer: You keep closely attuned to the needs and perspectives of customers and use this insight for the benefit of the business.
Our Ideal Candidate
The successful candidate will bring broad managed care leadership experience to this role with progressive Medicare Risk contracting and network development experience gained over a period of years. Prior business “ownership” and experience leading a healthcare business with financial accountability is highly desired, as is insight gained from experience in functions outside of contracting or network operations. A strong understanding of how integrated delivery systems, physician groups, and hospital systems think and operate is fundamental to this role, as is a passion/commitment to improving clinical quality and outcomes in the U.S. health care system.
Ten years of business leadership experience, with a minimum of five years in a managed care environment as the leader of a network development/provider relations function.
Experience analyzing the financial viability of complex provider contracts to include subcontracting entities, risk delegation, and other non-standard requirements associated with regulatory and legal contracts
Experience leading the “end-to-end” contract negotiation process through closure for different types of providers (hospitals, physicians, sub-acute care facilities, pharmacy networks) and delegated specialty services
Comprehensive knowledge of health plan finance and the compensation arrangements between health plans and providers, including plan funding, risk management and provider reimbursement. Must possess ability to identify health service expenses and implement cost control mechanisms within contracts
Experience identifying and recruiting providers to ensure network alignment with planned sales process execution, orienting providers and managing relationships, and driving improvement in provider satisfaction via education, communication and streamlining claims resolution
Prior operational leadership experience in sales, finance, health services, and/or medical management; demonstrated ability to partner across functions to create and deploy win/win strategies
Skill in driving results, thinking strategically and executing strategy effectively; thinking at an enterprise level
Bachelor’s degree in related field
MBA or graduate degree in Finance, Health Care Administration or a related field
Humana is an organization with careers that change lives—including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping egree in related field; advanced degree in business or related field preferred.others and to lead their best lives. If you’re ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for for you.
Apply now, or join our Talent Network so you can stay informed and up to date on what’s happening at Humana.
Contracting and Provider Relations
Work Environment Type
Yes, 20 % of the Time
Humana - 12 months ago
Humana Inc. (Humana) is a full-service benefits solutions company, offering an array of health and supplemental benefit plans for employer...