VP, Clinical Policy and Risk Management

Job not on LinkedIn

🔥 2 hours ago

🇺🇸 United States – Remote

⏰ Full Time

🔴 Lead

🔒 Insurance

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👻 Ghost score 10%

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Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Humana is a healthcare company dedicated to making a positive impact on the health of individuals, communities, and the healthcare system as a whole. With a focus on putting health first, Humana serves a diverse range of populations, including seniors and the military, providing Medicare Advantage HMO, PPO, and PFFS plans. Humana is committed to fostering a culture of belonging and mutual respect, offering competitive and flexible benefits to ensure the financial security of its employees and their families. The company prides itself on creating an inclusive workplace where everyone has the opportunity to succeed.

📋 Description

• Oversee a department comprising 7 direct reports and 250 associates leading CM/UM Risk Management, UM and CM audit teams, and policy governance • Identify, assess, and report operational and clinical risks within CM/UM processes to appropriate governance structures • Monitor CM/UM compliance and operational metrics, escalating and resolving issues impacting member care or regulatory compliance • Track, interpret, and implement CMS Federal and Medicaid State regulations affecting CM/UM • Support regulatory audits focused on CM/UM compliance and facilitate remediation • Lead risk mitigation efforts for care management and utilization management, including maturity assessments and oversight of issues and opportunities • Oversee CM/UM business continuity and work across leadership to resolve IOPs • Foster quality and continuous improvement within CM/UM control processes • Address legislative and regulatory issues affecting CM/UM operations, including fraud risk identification and mitigation • Partner with Legal, Compliance, Regulatory Affairs, and business leaders on emerging regulatory and legal risks, legislative requirements, audit and litigation readiness, and alignment with applicable laws • Report directly to the Senior Vice President – Clinical Operations

🎯 Requirements

• Bachelor’s degree required; MBA preferred • Active, unrestricted clinical license in the applicable discipline (e.g., RN, LCSW, LPC, LMFT, PharmD, MD/DO, or other relevant clinical credential) • Ability to apply clinical expertise, professional judgment, and regulatory knowledge to support business, operational, and member outcomes • 10+ years of experience in CM/UM risk management, regulatory compliance, process improvement, or related fields • 6+ years in leadership roles • Advanced knowledge of CM/UM operational controls, risk mitigation strategies, and regulatory requirements for Medicare and Medicaid • Expertise in internal controls, clinical and operational risk management, and IT technical controls within CM/UM environments • Exceptional project management skills, integrity, and business ethics • Ability to collaborate with stakeholders across the enterprise and influence outcomes in complex, matrixed environments • Excellent communication skills and executive presence

🏖️ Benefits

• Occasional travel to Humana's offices for training or meetings may be required • Self-provided internet service with minimum 25 Mbps download and 10 Mbps upload • Dedicated workspace to protect member PHI / HIPAA information