CMO, Utilization Management & Market Insights

Humana Inc; San Juan (PR); Remote; USD 250,000 - 450,000; Full time

Job summary

Humana Inc. seeks a visionary Chief Medical Officer, Utilization Management (UM) to lead the clinical strategy for Humana’s UM function across Medicaid and Medicare. You will oversee MD/ RN integration, risk management, and vendor relationships while driving performance improvements and Star Rating outcomes.

The role emphasizes evidence-based UM review, collaboration with senior leadership, and developing clinical leadership across the organization. Remote-eligible with travel as needed.

Qualifications

• MD/DO degree with current Board Certification.
• Minimum 10 years of combined leadership and/or Utilization Management experience.
• Passion for improving Star Ratings, review consistency, and health outcomes.
• Deep knowledge of medical, clinical, and behavioral science underpinning UM.
• Strong interpersonal, leadership, and business acumen.
• Proven ability to drive cross-functional results and champion clinical perspectives.

Responsibilities

• Set clinical strategy and lead the Utilization Management organization.
• Oversee the integration of medical doctors and registered nurses in UM across Medicaid and Medicare.
• Provide leadership in risk management, grievance and appeals, clinical contracting, vendor management, and UM dental review.
• Ensure the clinician’s perspective is central to organizational decision-making.
• Leverage analytics to inform strategy and performance improvement.
• Sponsor the development of clinical talent and leadership pipeline.

Skills

MD/DO

Board Certification

Leadership

Strategic thinking

UM expertise

Job description

Humana Inc. seeks a visionary Chief Medical Officer, Utilization Management (UM) to lead the clinical strategy for Humana’s UM function across Medicaid and Medicare. You will oversee MD/ RN integration, risk management, and vendor relationships while driving performance improvements and Star Rating outcomes.

The role emphasizes evidence-based UM review, collaboration with senior leadership, and developing clinical leadership across the organization. Remote-eligible with travel as needed.