VP, Clinical Policy & Risk Management

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Humana maintains a robust clinical risk management function to ensure effective risk mitigation, control, and governance processes across Care Management and Utilization Management. The mission of the Medicare and Medicaid Operational Risk Management Department is to partner with CM/UM teams to drive operational compliance, member access to care, and efficiency, while proactively identifying and managing risks related to care and utilization management.The Vice President, Clinical Policy and Risk Management will oversee a department comprising 5 direct reports that lead CM/UM Risk Management, UM and CM audit teams, policy governance and clinical learning. This role reports directly to the Senior Vice President – Clinical Operations.

Responsibilities

• Identify, assess, and report operational and clinical risks within CM/UM processes to appropriate governance structures.
• Monitor CM/UM compliance and operational metrics, ensuring escalation and resolution of any issues impacting member care or regulatory compliance.
• Track, interpret, and implement CMS Federal and Medicaid State regulations impacting CM/UM, ensuring timely and complete adoption.
• Support regulatory audits with emphasis on CM/UM compliance and facilitate remediation where necessary.
• Lead risk mitigation efforts related to 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 any IOPs administered.
• Foster quality and continuous improvement within CM/UM control processes, ensuring alignment with policies, standards, and applicable laws.
• Address legislative and regulatory issues with potential impact on CM/UM operations, including fraud risk identification and mitigation.
•  Lead the strategy, design, implementation, and continuous improvement of clinical learning programs that support onboarding, role readiness, compliance, and performance for Care Management and Utilization Management teams; oversee end-to-end learning solution development, including curriculum architecture, instructional design standards, learning technologies and systems administration, workflow integration, and new hire onboarding experiences
•  Partner closely with clinical, operational, compliance, and business leaders to ensure learning content is aligned to regulatory requirements, clinical processes, system functionality, and business priorities; establish scalable onboarding and learning pathways, optimize learner experience across platforms, and use performance data, audit findings, and operational insights to strengthen adoption, reduce risk, and improve readiness and effectiveness of the clinical workforce.

Use your skills to make an impact

Required Qualifications

• Bachelor’s degree
• Extensive experience (10+ years) in CM/UM risk management, regulatory compliance, process improvement, or related fields, with several years in leadership roles.
• Advanced knowledge of CM/UM operational controls, risk mitigation strategies, and regulatory requirements for Medicare and Medicaid.
• Demonstrated 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.

Preferred Qualifications

• MBA

• Relevant professional credentials (CPA, CIA, CISSP, JD, SOA, RN, CCM, or similar)

Scheduled Weekly Hours

40

About us

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.

​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.