VP, Medicaid Clinical Operations

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🐊 Florida, Kentucky – Remote

🐊 Florida – Remote 🐎 Kentucky – Remote

⏰ Full Time

🔴 Lead

🏥 Clinical Operations

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Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

⚕️ 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

• Lead Medicaid Clinical Operations, including clinical and nonclinical teams supporting utilization management, care management/service coordination, program operations, process improvement, training, and project execution. • Establish clear operating rhythms, accountability structures, workforce productivity expectations, and performance management processes across distributed clinical operations teams. • Build and sustain an engaged, high-performing leadership culture focused on associate development, retention, operational discipline, and measurable outcomes. • Develop and execute Medicaid clinical operations strategies that support growth, market expansion, state contract requirements, enterprise priorities, and scalable operating model transformation. • Translate clinical strategy, market commitments, and program designs into operational workflows, staffing models, performance targets, and implementation plans. • Oversee Medicaid utilization management and care management/service coordination functions, ensuring consistent clinical practices, regulatory compliance, timely decision-making, and appropriate escalation management. • Strengthen care navigation, member access, provider coordination, and interventions that reduce avoidable utilization and improve health outcomes. • Partner with Product, Technology, Data, Analytics, and Operations teams to translate Clinical Operation’s needs, regulatory requirements, workflow gaps, and performance priorities into clear business requirements, use cases, and solution expectations. • Establish, monitor, and improve key performance metrics, including quality, compliance, cost of care, access, utilization, productivity, service levels, member experience, provider experience, revenue, margin, and client or contract performance commitments.

🎯 Requirements

• Bachelor’s degree required; advanced degree in nursing, public health, healthcare administration, business administration, social work, or a related field preferred. • Strongly preferred Clinical license, nursing degree, or other healthcare credential; MD is not required. • 10 plus years of progressive experience in Medicaid, managed care, clinical operations, utilization management, care management, population health, health services operations, or healthcare transformation. • 5 plus years leading large, distributed clinical and/or operational teams, including leaders of leaders, through scale, change, and performance improvement. • Deep understanding of Medicaid programs, state contract requirements, regulatory expectations, integrated care models, LTSS, behavioral health, complex populations, and DSNP coordination. • Demonstrated ability to translate strategy into operational execution, standardized workflows, measurable outcomes, and sustainable performance improvement. • Experience partnering with Product, Technology, Data, and Analytics teams to translate clinical operations needs into business requirements, workflow priorities, reporting needs, user adoption considerations, and measurable solution outcomes preferred. • Strong financial acumen, including experience managing budgets, staffing models, productivity, labor efficiency, revenue, margin, and operating performance. • Proven ability to lead through ambiguity, influence cross-functionally, manage risk, engage senior stakeholders, and communicate effectively with executive audiences.

🏖️ Benefits

• Health insurance • 401(k) retirement plans • Paid time off • Flexible work arrangements • Professional development opportunities