Provider Relations Representative

Become a part of our caring community

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.

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, 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
• 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