Remote VP, Clinical Policy & Risk Management

Humana; United States; Remote; USD 180,000 - 260,000; Full time

Job summary

Humana seeks a Vice President, Clinical Policy and Risk Management to lead CM/UM risk management, audits, and policy governance. This remote role reports to the SVP – Clinical Operations and oversees 7 direct reports and 250 associates, driving regulatory compliance and continuous improvement across care management and utilization management.

You will partner with Legal, Compliance, and business leaders to interpret CMS and Medicaid requirements, manage risk, and ensure alignment with federal

Qualifications

• Bachelor’s degree required; MBA preferred.
• Active, unrestricted clinical license in the applicable discipline.
• 10+ years in CM/UM risk management or related fields; 6+ years in leadership.
• Advanced knowledge of CM/UM operational controls and regulatory requirements for Medicare/Medicaid.
• Expertise in internal controls, clinical and operational risk management, and IT controls.
• Excellent communication skills and executive presence.

Responsibilities

• Identify, assess, and report operational and clinical risks within CM/UM processes.
• Monitor CM/UM compliance and metrics; escalate and resolve issues impacting member care or regulatory compliance.
• Track and interpret CMS Federal and Medicaid regulations; ensure timely adoption.
• Support regulatory audits with emphasis on CM/UM compliance and remediation.
• Lead risk mitigation efforts, including maturity assessments and oversight of issues.
• Oversee CM/UM business continuity and cross-functional collaboration to resolve IOPs.
• Foster quality and continuous improvement within CM/UM controls and policies.
• Address legislative and regulatory issues; assess potential impact on CM/UM operations.
• Partner with Legal, Compliance, Regulatory Affairs to align policies with laws.

Skills

Regulatory compliance

Leadership experience

Executive communication

Risk management

Project management

Education

Bachelor’s degree

MBA preferred

Job description

Humana seeks a Vice President, Clinical Policy and Risk Management to lead CM/UM risk management, audits, and policy governance. This remote role reports to the SVP – Clinical Operations and oversees 7 direct reports and 250 associates, driving regulatory compliance and continuous improvement across care management and utilization management.

You will partner with Legal, Compliance, and business leaders to interpret CMS and Medicaid requirements, manage risk, and ensure alignment with federal