Director Medicaid Provider Services State of OH

Profile

Job Information
Humana
Director Medicaid Provider Services (State of OH)
in
Cincinnati
Ohio
Description
The Director Medicaid Provider Services oversees the plan's strategic provider services, provider engagement and network development. They coordinate workforce development initiatives and work collaboratively with Humana business area leads, other contracted MCO's and the Department as prescribed. They maintain provider relations to support customer service activities through data integrity management and gathering of provider claims data needed for service operations. Responsible for the retention of the plan's network of providers, creating a qualified, serviceable and comprehensive network. This is a collaborative role requiring critical thinking skills, independence, leadership, a strategic mindset, and attention to detail. of how organization capabilities interrelate across the function or segment.
Responsibilities
Supports the development and growth of positive, long-term relationships with physicians, providers and healthcare systems in order to maintain and improve financial and quality performance within the contracted working relationship with the health plan.
Represents the scope of health plan/provider relationship across such areas as financial performance, incentive programs, quality and clinical management, population health, data sharing, connectivity, documentation and coding, HEDIS and STARs performance, operational improvements and other areas as they relate to provider performance, member experience, market growth, provider experience and operational excellence.
Provides market oversight and governance of provider audits, provider surveys, provider service and relations, credentialing, and contract management systems. Provides oversight and governance of the executed processes for intake and management of provider perceived service failures.
Work closely with Data Management teams on claims processing, resolution issues, and provider performance tool enhancements.
Work closely with Product Teams to ensure new developments align with provider expectations.
Drives performance and executes on strategic initiatives within the provider network.
In coordination with health system leadership, develops annual and quarterly strategic targeting objectives for provider relations team in alignment with market strategies and initiatives.
Reviews, assesses and develops outreach strategies based on available and appropriate data; and provides consistent communication of goals/outcomes.
Partners with marketing to develop outreach collateral and strategies to be used uniformly throughout the market.
Provides market oversight and governance of the management of provider data for the health plan including but not limited to demographics, rates, and contract intent.
Coordinates and collaborates with a matrix team of provider service and contracting representatives to ensure that Humana processes are aligned with State contract and regulatory requirements. Ensures compliance with contractual requirements as it relates to the Market network and directs process improvement to address network non-compliance, market strategy and initiatives.
Collaborates weekly (or as needed) with health system leadership to discuss trends, business growth opportunities, obstacles to service line retention, and results from Provider Relations outreach activities.
Dedicated Full time responsibility to the Ohio Medicaid plan
Educational and Experience Requirements:
Bachelor's degree
3 or more years of provider contracting or physician network development experience
Experience with analyzing, understanding and communicating financial trends
2 or more years of project leadership experience
2 or more years of management experience
Knowledge of Medicaid regulatory requirements
Intermediate knowledge of Microsoft Word and Excel
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Experience with credentialing and contract management systems preferred
Working knowledge in the areas of Practice Management, Long-Term Acute Care, home health, home infusion, behavioral health, ambulatory surgery, and the outpatient experience preferred
Additional Information
Requires travel
This position will be report directly to the Ohio Medicaid Chief Operations Officer (COO).
Scheduled Weekly Hours
40

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