VP, Clinical Policy and Risk Management

This is a fully remote position, open to applicants in United States.

📋 Description

• Manage a department consisting of 7 direct reports and 250 associates, overseeing CM/UM Risk Management, UM and CM audit teams, and policy governance.

• Identify, evaluate, and report operational and clinical risks within CM/UM processes to the relevant governance structures.

• Monitor compliance and operational metrics in CM/UM, addressing and resolving issues that affect member care or regulatory adherence.

• Track, analyze, and implement CMS Federal and Medicaid State regulations that impact CM/UM.

• Assist with regulatory audits aimed at ensuring CM/UM compliance and facilitate necessary remediation efforts.

• Direct risk mitigation initiatives for care management and utilization management, including conducting maturity assessments and overseeing issues and opportunities.

• Supervise CM/UM business continuity and collaborate with leadership to address IOPs.

• Promote quality and continuous improvement in CM/UM control processes.

• Tackle legislative and regulatory challenges impacting CM/UM operations, including the identification and mitigation of fraud risks.

• Collaborate with Legal, Compliance, Regulatory Affairs, and business leaders on emerging regulatory and legal risks, legislative requirements, audit and litigation preparedness, and alignment with relevant laws.

• Report directly to the Senior Vice President of Clinical Operations.

⛳️ Requirements

• Bachelor's degree is required; an MBA is preferred.

• Active and unrestricted clinical license in the relevant discipline (e.g., RN, LCSW, LPC, LMFT, PharmD, MD/DO, or other applicable clinical credential).

• Capability to apply clinical expertise, professional judgment, and regulatory knowledge to enhance business, operational, and member outcomes.

• A minimum of 10 years of experience in CM/UM risk management, regulatory compliance, process improvement, or related areas.

• At least 6 years in leadership positions.

• Advanced comprehension of CM/UM operational controls, risk mitigation techniques, and regulatory requirements for Medicare and Medicaid.

• Proficiency in internal controls, clinical and operational risk management, and IT technical controls within CM/UM settings.

• Outstanding project management abilities, integrity, and strong business ethics.

• Strong ability to collaborate with stakeholders across the organization and influence outcomes in complex, matrixed environments.

• Excellent communication skills and a commanding executive presence.

🏝️ Benefits

• Occasional travel to Humana's offices for training or meetings may be necessary.

• Self-provided internet service with a minimum of 25 Mbps download and 10 Mbps upload speed.

• Designated workspace to safeguard member PHI / HIPAA information.