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The Provider Relations Representative is responsible for day-to-day, front-line relationship management for network providers in Humana Healthy Horizons in Virginia Medicaid Plan. This role supports provider onboarding, training, education, and inquiry/issue support and resolution. The individual in this role should have critical thinking/problem solving skills, an understanding of health plan operations, and strong interpersonal skills. This role develops and grows positive, long-term relationships with physicians, providers and healthcare systems.

• Serve as primary relationship manager with assigned providers to ensure positive provider experience with Humana Healthy Horizons and promote network retention
• Meet regularly, both in-person and virtually, with assigned providers to conduct training and education, including, but not limited to, required annual trainings, periodic updates to and/or reviews of Humana policies and procedures, and Humana systems training and updates
• Support newly assigned providers with onboarding, including hosting orientation session(s)
• Respond to assigned provider inquiries and support prompt issue resolution, including, where necessary, collaboration with appropriate enterprise business teams (ex., claims payment, prior authorizations & referrals)
• Work with internal resources and systems (e.g., claims, reimbursement, provider enrollment) to provide the Exceptional Experience in all provider interactions
• Create provider trainings based on provider feedback, trends in claims or process changes
• Educate provider on location and content of all provider facing materials (Orientation, Provider Manual, Newsletter, Program Updates, Etc.)
• Convene regular meetings with providers, including organizing agendas, materials, meeting minutes, other team members (clinical, provider engagement), to discuss key operational, clinical, and quality related topics
• Educate on processes including claims submissions, recoupments, reconsiderations, authorizations, referrals, medical record management, Availity, Quality resources, and member resources
• Communicate updates on Humana's policies and procedures and Cardinal Care programmatic updates
• Coordinate periodic regional provider townhalls and/or trainings
• Attend Network Meetings/Conferences
• Ensure compliance with all Virginia managed care contractual requirements for provider relations, such as timeframes for claims dispute resolution, provider complaints, provider inquiry response, etc.

Use your skills to make an impact

Required Qualifications

• Must reside in the Tidewater Region of Virginia
• 2+ years of health care or managed care experience working with providers (e.g., provider relations, claims education)
• Experience working with physical health providers, facilities, ancillary providers, and/or FQHCs
• Experience in provider operations, building strong relationships with provider organizations, financial/contracting arrangements, and/or regulatory requirements
• Exceptional relationship management and interpersonal skills
• Proficiency in analyzing, understanding, resolving, and communicating complex issues
• Exceptional time management and ability to manage multiple priorities in a fast-paced environment
• Thorough understanding of managed care contracts, including contract language and reimbursement
• Exceptional written and verbal communication skills
• Strong presentation and facilitation skills
• Knowledge of Microsoft Office applications
• You are field based in Virginia and requires frequent travels to provider and Humana locations

Preferred Qualifications

• Experience with Virginia Medicaid
• Understanding of claims systems, adjudication, submission processes, coding, and/or dispute resolution
• Understanding of service coordination, prior authorizations, and other health plan processes
• Understanding of value-based payment programs

Additional Information

Must reside in the Tidewater Region of Virginia

• Workstyle: This is a remote position that will require you to travel.
• Travel: Up to 25% of the time to Humana Healthy Horizons office in Glen Allen, VA for collaboration and face to face meetings as well as field interactions with staff, providers, members, and their families.
• Workdays and Hours: Monday - Friday; 8:00am - 5:00pm Eastern Standard Time (EST).
• Language Assessment Statement: Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.

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; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$59,300 - $80,900 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About us
About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer atHumana.comand atCenterWell.com.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.