Process Improvement Professional - National Clinical Ops Medicaid

Humana; Kentucky; Remote; USD 65,000 - 89,000; Full time

Benefits offered by this job

Bonus eligible

Job summary

Humana is seeking a Process Improvement Professional within the National Medicaid Operations Utilization Management Process Improvement & Enablement Team. You will partner with Clinical Operations and subject matter experts to standardize and optimize Medicaid clinical processes, ensuring alignment with NCQA requirements.

The role analyzes current processes, develops repeatable improvements, and supports cross-functional implementation and evaluation of performance, with travel occasional and a

Qualifications

• Bachelor's degree or 3+ years relevant experience in lieu of degree.
• 3+ years of experience navigating multiple databases, systems, and screens, with proficiency in collaboration platforms such as Zoom, Microsoft Teams, as well as Microsoft Office tools including Outlook, Word, Excel, and PowerPoint.
• Prior experience in a fast-paced insurance or healthcare setting.
• Experience creating and maintaining compliant, user-friendly SharePoint sites.

Responsibilities

• Initiates, develops, and recommends best business practices and procedures for physical health clinical and nonclinical teams.
• Standardizes and maintains Medicaid MD operating procedures (SOPs), workflows, and templates.
• Manages Medicaid MD controlled document updates (intake, versioning, approvals, publication).
• Coordinates Medicaid MD training/attestation and adoption.
• Establishes consistent practices for Medicaid MD procedures to reduce variation across markets.
• Interprets organizational policies and procedures to determine appropriate actions, ensure compliance, and support effective decision-making.
• Executes on process improvement/development and evaluation strategy and analyzes results.
• Makes recommendations for improvement based on analysis of results.

Skills

Databases navigation

Zoom & Teams

MS Office suite

Healthcare experience

Education

Bachelor's degree or 3+ years relevant experience in lieu of degree

Tools

SharePoint

Power BI

Job description

Become a part of our caring community

This role, within the National Medicaid Operations Utilization Management Process Improvement & Enablement Team, will partner closely with Clinical Operations, subject matter experts, and clinical teams to support Medicaid Medical Directors. The position is responsible for ensuring clinical operational processes are standardized, effective, and aligned with applicable governing and NCQA requirements.

The Process Improvement Professional analyzes and measures the effectiveness of existing business processes and develops sustainable, repeatable, and quantifiable process improvements. This role requires the ability to interpret complex information, assess operational needs, and independently determine appropriate courses of action. Work assignments are varied and may involve cross-functional collaboration, process development, implementation support, and ongoing evaluation of process performance.

• Responsible for initiating, developing, and recommending best business practices and procedures for physical health clinical and nonclinical teams
• Standardizes and maintains Medicaid MD operating procedures (SOPs), workflows, and templates
• Manages Medicaid MD controlled document updates (intake, versioning, approvals, publication)
• Coordinates Medicaid MD training/attestation and adoption.
• Establishes consistent practices for Medicaid MD procedures to reduce variation across markets.
• Interprets organizational policies and procedures to determine appropriate actions, ensure compliance, and support effective decision‑making.
• Executes on process improvement/development and evaluation strategy and analyzes results.
• Makes recommendations for improvement based on analysis of results.

Required Qualifications

Use your skills to make an impact

• Bachelor's degree or 3+ years relevant experience in lieu of degree
• 3+ years of experience efficiently navigating multiple databases, systems, and screens simultaneously, with proficiency in collaboration platforms such as Zoom, Microsoft Teams, as well as Microsoft Office tools including Outlook, LUCID, Word, Excel, and PowerPoint.
• Prior experience in a fast‑paced insurance or healthcare setting
• Experience creating and maintaining compliant, user‑friendly SharePoint sites.

Preferred Qualifications

• Previous Medicare/Medicaid or Health Plan experience in Utilization Management
• Power BI experience

Additional Information

• Schedule: Monday to Friday from 8 am to 5 pm Eastern Standard Time zone
• Work Location: Remote

Work at Home Requirements: 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 required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay 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.

$65,000 - $88,600 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

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 atHumana.comand atCenterWell.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.