Provider Relations Representative

The Provider Relations Representative is responsible for day-to-day, front-line relationship management for network providers in Humana.

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 BH providers.

Responsibilities:

• Serve as primary relationship manager with assigned providers to ensure positive provider experience with Humana’s Dual Fully Integrated and Healthy Horizon plan of Illinois 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, Availability, 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.

Requirements:

• Candidate must reside within Cook County in Illinois.
• 2 or more years of health care or managed care experience working with providers (e.g., provider relations, claims education)
• Experience with Illinois Medicaid
• Experience working with Behavioral Health providers and Community Mental Health Centers.
• Experience in provider operations, building strong relationships with provider organizations, financial/contracting arrangements, and/or regulatory requirements
• Exceptional relationship management and interpersonal skills
• Thorough understanding of managed care contracts, including contract language and reimbursement
• Position is field based in Illinois and requires frequent travels to provider and Humana locations

Preferred Qualifications:

• 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:

• This role is considered patient facing and is part of Humana’s Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
• This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.
• 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: $59,300 - $80,900 per year

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.