[Remote] Clinical Business Lead at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Medicare, Health InsuranceIndustries

Requirements

Bachelor’s degree in a science or health-related field
Minimum of 5 years of experience in the healthcare industry
Minimum 3 years of experience in data analytics, clinical operations, care management, quality improvement, or vendor oversight
Proficient in analyzing and representing data using visualization tools (e.g., Excel, Tableau, Power BI) and interpreting it for various audiences
Strong understanding of value-based care, population health, and clinical quality metrics
Experience managing or supporting third-party vendor relationships in a health setting

Responsibilities

Analyze chronic condition performance to provide insights to provider groups for awareness, education, and action plans
Evaluate the effectiveness of clinical program initiatives through analysis of downstream impact on facility and provider performance in value-based programs
Identify opportunities for new clinical program initiatives by assessing cost and utilization drivers, with a focus on chronic conditions
Support facility case review discussions with pre-meeting analysis of submitted case reviews as needed
Prepare data and evaluate performance to support RVP and HSD in governance and delegation oversight committees, and interact with corporate delegation compliance and auditing teams
Collaborate with cross-functional teams and internal stakeholders to ensure alignment of clinical strategies with regional executive leadership
Serve as a clinical liaison to the provider engagement team to ensure consistent execution of initiatives
Serve as a clinical liaison for provider partners regarding utilization management operations questions, interfacing with central UM team
Collaborate with the delegation team to identify and resolve performance issues or access concerns
Support regional leadership in maintaining compliance with clinical best practices and regulatory standards
Participate in continuous quality improvement initiatives, including root cause analysis and best practices to close care gaps
Coordinate the implementation of clinical vendor programs across the region, ensuring operational readiness, provider education, and ongoing support for seamless integration
Assist in the evaluation of clinical program pilots and vendor-supported initiatives through analysis and monitoring of key performance indicators
Track vendor performance metrics and collaborate with finance team to prepare performance reports to support data-driven decision making and ROI
Provide insights to inform program scalability and effectiveness

Skills

Key technologies and capabilities for this role

Data AnalyticsPerformance MonitoringClinical StrategyMedicare AdvantageChronic Condition ManagementValue-Based ProgramsProvider RelationsGovernance OversightQuality ImprovementUtilization AnalysisCase ReviewProgram ImplementationVendor Management

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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