AVP, Medicaid Utilization & Care Strategy

Humana Inc; Cheyenne (WY); On-site; USD 180,000 - 260,000; Full time

Job summary

Humana Inc is seeking an AVP, Utilization and Care Management Strategy to provide enterprise strategic leadership for Medicaid utilization management, care management, clinical policy governance, affordability initiatives, and performance oversight. Reporting to the VP, Medicaid Clinical Strategy, the role shapes priorities and drives scalable execution across Medicaid markets.

This leader partners with Clinical Operations, Population Health Management, Behavioral Health, Pharmacy, Care

Responsibilities

• Lead enterprise Medicaid utilization and care management strategy, including prior authorization strategy, Medicaid clinical policy governance, medical expense strategy, site-of-care optimization, provider practice variation, high-risk member strategy, and targeted affordability initiatives.
• Establish strategic direction, governance routines, performance expectations, and enterprise priorities for Medicaid utilization and care management, in partnership with operational leaders accountable for day-to-day execution.
• Oversee Medicaid care management strategy at the enterprise level to ensure programs are member-centered, data-driven, clinically effective, operationally scalable, and aligned with utilization, quality, access, regulatory, and affordability goals.
• Integrate utilization management and care management strategies to identify members with rising risk, complex needs, avoidable utilization, care gaps, and opportunities for earlier intervention, improved care coordination, and more appropriate site-of-care decisions.
• Use utilization, authorization, denial, appeal, claims, care management, quality, medical expense,

Job description

Humana Inc is seeking an AVP, Utilization and Care Management Strategy to provide enterprise strategic leadership for Medicaid utilization management, care management, clinical policy governance, affordability initiatives, and performance oversight. Reporting to the VP, Medicaid Clinical Strategy, the role shapes priorities and drives scalable execution across Medicaid markets.

This leader partners with Clinical Operations, Population Health Management, Behavioral Health, Pharmacy, Care