Humana · 1 day ago
Network Optimization Principal
United States
Full-time
Remote
Senior Level, Lead/Staff
$126K/yr - $174K/yr
6+ years expHumana is a company committed to putting health first for their teammates and customers. The Principal, Network Optimization oversees the strategic development of the SC Medicaid provider network, driving optimization and compliance while collaborating with various teams to enhance care delivery and operational efficiency.
Health CareHealth InsuranceInsuranceVenture Capital
Responsibilities
Define & execute network development strategy that promotes access, adequacy, and drives high value care delivery in alignment with financial, operational and clinical goals
Maintain annual and ad hoc updates to network development plan
Subject Matter Expert (SME) on SC contractual requirement for network standards and penalties for noncompliance
Identify areas of risk with Medicaid NetAd reporting and strategize network time & distance, provider-to-enrollee ratio, and/or timely access gap closures by targeting providers for recruitment to Humana network and monitoring progress
Subject Matter Expert (SME) on provider crosswalk/mapping from Humana’s data to state file and ensure accuracy on data submissions to the state agency
Oversee ad hoc contracting/re-contracting campaigns for new or expanded services
Collaborate with clinical and utilization management (UM) to identify access to care issues that include timely access standards, geographic barriers, close panel limitations, operational issues (i.e.: Problems with claims payment, staffing, rates), and member-specific barriers
Manage network assessment and build for value-added benefit and in-lieu of services
Root cause load inaccuracies that result in provider not reflecting correctly on state provider files and/or directory. Relay to appropriate department to address issue
Ensure required submissions to state agency for incurable gaps and terminations
Monitor terminations to account for termination impact and adequacy fluctuations
Oversee required communication processes to notify members & providers
Develop tracking system for transparency
Sets strategy and identify providers for participation in value-based payment (VBP) programs for SC according to contract requirements
Lead routine value-based payment (VBP) governance forum to manage VBP strategy execution and review new VBP deals; manage approvals for non-standard FFS or VBP rate requests
Identify trend-bender opportunities through contract renegotiation and VBP
Provides market oversight and governance of the management of SC value-based payment models
Monitor performance against key performance indicators (KPIs) and ensure compliance with contractual commitments and requirements. Partner with health plan leadership to improve KPI performance and ensure contractual compliance
Participates in operating meetings, as needed, for key provider relationships to facilitate strategic initiatives and improved performance
Works collaboratively with Chief Operating Officer, Provider Services Director, health plan finance, corporate Network Operations, clinical and quality teams to achieve strategic goals and priorities
Qualification
Required
Bachelor's Degree
6+ years' experience working with a managed care organization or as a consultant in a network/contract management role, such as contracting, provider services, etc
2+ years of experience in provider network development, including contracting, network operations, and/or network maintenance
4+ years of experience in value-based contracting models
2+ years of experience in data analysis
Proficiency with a wide range of physician/facility/ancillary contract reimbursement methodologies
Prior leadership and management experience
Ability to manage multiple priorities in a fast-paced environment
Experience working in a matrixed organization and influencing change and direction
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
The applicant must be located in or willing to relocate to SC– (if market has local Humana office) position may be based at our office in[city] or remote within the state
Preferred
Master's Degree
Experience with the SC Medicaid contract, including network adequacy requirements and standards for provider relations compliance
Benefits
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
Company
Humana
Humana is a health insurance provider for individuals, families, and businesses.
10001+ employees
H1B Sponsorship
Humana has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (282)
2024 (246)
2023 (284)
2022 (274)
2021 (212)
2020 (84)
Funding
Current Stage
Public CompanyTotal Funding
$13.07B2025-05-30Post Ipo Debt· $5B
2025-03-03Post Ipo Debt· $1.25B
2024-03-11Post Ipo Debt· $2.25B
Leadership Team
Jim Rechtin
CEO and President
Colin Drylie
Senior Vice President, Experience Transformation
Recent News
2026-01-13
2026-01-09
2026-01-07
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