Remote Senior Clinical Consultant, Nationwide

Humana

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Location: Nationwide
Location Type: Remote
Schedule: Full_time
Req: R-342891

Become a part of our caring community and help us put health first

The Senior Provider Contracting Professional initiates, negotiates, and executes physician, hospital, and/or other provider contracts and agreements for an organization that provides health insurance. The Senior Provider Contracting Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

 

The Senior Provider Contracting Professional will be accountable to:

  • Communicate effectively and act as a strategic intermediary between the Markets (multiple levels of leadership) and the Clinical Contracting Support Team with the Medicare Markets
  • Collaborate with Market contracting organizations to identify opportunities for clinical solution implementations; engage the correct SMEs in appropriate dialogues
  • Partner directly with Clinical and non-Clinical teams from across the organization leadership on the execution of the above activities, as well as in the identification of potential new opportunities
  • Assist in the creation of scalable, repeatable, compliant, and standardized implementations of UM Processes
  • Assist in the development, iteration, launch and utilization of tools/tracking mechanisms
  • Assist in the identification, creation, value assessment, compliant clinical programs aimed at reducing provider abrasion instances without having to agree to contract concessions terms
  • Provide clinical data reporting for various contract themes and financial impacts to the enterprise.
  • Deliver on a wide range of strategic and tactical activities, including contracting/business development, capability definition and advancement, organizational level strategy, market level opportunities, and partnership on related activities as part of a matrix environment
  • Convert strategy/tactical priorities into business cases and initiatives while prioritizing timelines and ensuring consensus and execution
  • Understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
  • Make decisions regarding own work methods, occasionally in ambiguous situations, and require minimal direction
  • Follows established CMS, Humana Policy guidelines, and compliance procedures

Responsibilities will include, but not be limited to the following:

  • Collaborate with Markets, National Provider, and Interoperability teams to drive electronic connectivity and to support clinical processes and alternatives to ALC Alternative Level of Care (ALC) Front End Review (FER) Exclusions, and Independent Review Organization(IRO) language concessions
  • Guide or consult to optimal performance of clinical/quality metrics
  • Drive clinical solutions to solve for provider abrasion (non-contractual solutions, UM clinical levers, discharge planning, etc.)
  • Implement, manage, and support contractual Utilization Management & other clinical  operations

Use your skills to make an impact

Required Qualifications

  • Bachelor’s degree in professional or healthcare related field
  • Five (5) plus years of experience in clinical areas such as: Utilization/Case Management, Claims Resolution, Contract/Market Management, and/or Healthcare Administration
  • Experience working as a Subject Matter Expert/Mentor, manager, or strategy lead
  • Strong understanding of CMS Policy & Humana Clinical Policy and Procedures
  • Understanding of economic, financial, and clinical operational concepts
  • Excellent written and verbal communication skills
  • Ability to manage multiple priorities in a fast-paced environment
  • Proficiency in MS Office applications

Preferred Qualifications

  • Registered Nurse- Licensed as Individual state or multi-state licensure (MSL)
  • Master’s degree in business, Finance or other related field
  • 2 – 5 years of experience in UM related to managed care contracts with physician, hospital and/or other UM Clinical programs
  • Proficiency in analyzing, understanding, and communicating impact of contract terms or payment structures and reimbursement rates to providers
  • Demonstrate passion about contributing to an organization focused on continuously improving consumer experiences

Work-At-Home Requirements

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

  • At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
  • Satellite, cellular and microwave connection can be used only if approved by leadership
  • Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
  • Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
  • Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

 

 

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.

 

$76,800 – $105,800 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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large.

 

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 because he or she is a protected veteran. It is also the policy of  Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.