Remote VP, Clinical Policy & Risk Management

Humana Inc; Cheyenne (WY); Remote; USD 220,000 - 320,000; Full time

Job summary

Humana Inc. seeks a Vice President, Clinical Policy and Risk Management to oversee a large CM/UM risk and policy governance organization. The role reports to the Senior Vice President – Clinical Operations and drives compliance and risk mitigation across CM/UM programs.

The position leads audit teams, policy governance, and cross-functional collaboration with Legal, Compliance, and business leaders. A clinical license and 10+ years in CM/UM risk are required.

Qualifications

• Bachelor’s degree required; MBA preferred.
• Active, unrestricted clinical license in applicable discipline (e.g., RN, LCSW, LPC, LMFT, PharmD, MD/DO).
• 10+ years in CM/UM risk management, regulatory compliance, process improvement, or related fields; 6+ years in leadership.

Responsibilities

• Identify, assess, and report operational and clinical risks within CM/UM processes to governance structures.
• Monitor CM/UM compliance and metrics; escalate and resolve issues affecting member care or regulatory compliance.
• Track, interpret, and implement CMS Federal and Medicaid State regulations impacting CM/UM.
• Support regulatory audits with emphasis on CM/UM compliance and remediation.
• Lead risk mitigation efforts related to care management and utilization management.

Skills

Executive leadership

Regulatory knowledge

Stakeholder collaboration

Project management

Strategic thinking

Education

Bachelor’s degree

MBA preferred

Active clinical license (RN/LCSW/LPC/LMFT/PharmD/MD/DO)

Job description

Humana Inc. seeks a Vice President, Clinical Policy and Risk Management to oversee a large CM/UM risk and policy governance organization. The role reports to the Senior Vice President – Clinical Operations and drives compliance and risk mitigation across CM/UM programs.

The position leads audit teams, policy governance, and cross-functional collaboration with Legal, Compliance, and business leaders. A clinical license and 10+ years in CM/UM risk are required.