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The Utilization Management (UM) Director, Clinical Strategy and Practice for Medicaid builds strategies for development, engagement, best clinical practices and processes for clinical community within the enterprise. The Director, Clinical Strategy and Practice requires an in-depth understanding of how organization capabilities interrelate across the function or segment.
The Utilization Management (UM) Director, Clinical Strategy and Practice for Medicaid is responsible for leading the deployment of new markets, governance, and strategic development of Utilization Management (UM) processes and workflows across Medicaid markets. This role ensures consistency in structure, policies, and procedures while driving innovative solutions to enhance efficiency and outcomes in Medicaid UM. The position requires a strong focus on strategic planning, collaboration across departments, and a commitment to high-quality service delivery in a complex, multi-state environment. In this newly defined role, the Director, Clinical Strategy and Practice will also provide ongoing management and strategy support. This position will report directly to the Associate Vice President of Clinical Strategy and Practice for Medicaid.
Key Responsibilities
Oversees deployment of Utilization Management (UM) processes and workflows for new Medicaid states.
Oversee standardization of UM processes for existing Medicaid markets.
Oversee operations of existing market centralization.
Establish and maintain governance for UM structure, policies, and procedures across Medicaid states to ensure compliance and operational consistency.
Drive implementation of new market initiatives, including processes and procedures to align with state and federal Medicaid requirements.
Design and execute new workflows, processes, and strategies to improve outpatient UM operations.
Develop strategic plans to streamline and enhance outpatient UM processes across Medicaid markets.
Lead UM-related workstreams for Medicaid Requests for Proposals (RFPs), including mapping UM components for new state bids.
Oversight and coordination of DSNP strategy and programs
Use your skills to make an impact
Required Qualifications
Registered nurse (RN) with unrestricted licensed OR independent licensed clinical social worker
2-5 yrs of previous senior leadership experience in the healthcare industry
3+ years of experience in Medicaid or healthcare Utilization Management, with a focus on outpatient care.
Proven expertise in process development, strategic planning, and program implementation.
Innovative leader who can drive transformational initiatives, ensure operational excellence, and positively impact Medicaid utilization management outcomes.
Excellent relationship-building skills and proven ability to work collaboratively through various departments and functional areas, promoting a culture of proactive teamwork.
Preferred Qualifications
Bachelor's degree
Proven leadership experience Director Level and above.
Strong leadership skills and ability to work effectively in a cross-functional, matrixed environment.
2+ yrs Payer experience with responsibility for the creation and ownership of strategies for a large business unit.
This person will also have a proven record of success in orchestrating the efforts of cross-functional colleagues in large-scale projects.
Additional Information
This position is open to work remote
Work at Home Criteria *?*
To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees 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.?
Employees 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 employees 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.?
?* *Interview Format *?*
As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule *.*
Strategic thinker with the ability to design and execute large-scale implementation plans.
Proficient in analyzing data and identifying performance improvement opportunities.
Adept at managing complex projects and leading diverse teams.
Experience with RFP development and state Medicaid requirements.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40Pay 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.
$150,000 - $206,300 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.
Application Deadline: 06-15-2025
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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.