DSNP Strategy Advancement Advisor

Employment Type: Full-time

Position Overview

Become a part of our caring community and help us put health first. The DSNP Strategy Advancement Advisor provides data-based strategic direction to identify and address business issues and opportunities. This role provides business intelligence and strategic planning support for business segments or the company at large. The Strategy Advancement Advisor works on problems of diverse scope and complexity ranging from moderate to substantial.

The DSNP Strategy Advancement Advisor leads initiatives to analyze complex business problems and issues using data from internal and external sources. This role brings expertise or identifies subject matter experts in support of multi-functional efforts to identify, interpret, and produce recommendations and plans based on company and external data analysis. Ensures that policies and procedures align with corporate vision. Selects, develops, and evaluates personnel ensuring efficient operation of the function. Advises executives to develop functional strategies (often segment specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision. Uses independent judgment requiring analysis of variable factors and determining the best course of action.

Key Functions

• Serves as a liaison between Humana utilization management (UM) operations, Humana’s Risk and Compliance lines of defense, and the State of Michigan regarding prior authorization reviews, prepayment retrospective reviews, and any additional utilization management functions.
• Develop and implement utilization management strategies that align with organizational goals.
• Ensure the efficient use of healthcare resources while maintaining high-quality patient care.
• Serves as the primary liaison between Medicare and Medicaid teams for all DSNP activities.
• Understands and clearly articulates differences and intersections between Medicare and Medicaid Utilization Management processes.
• Coordinates and facilitates cross-functional meetings focused on DSNP planning, UM alignment, and process resolution.
• Identifies and addresses any concerns related to UM workflows, ensuring clarity and consistency across both lines of business.
• Supports state reporting efforts by understanding requirements and ensuring there is clear ownership and accountability.
• Participates in DSNP implementation planning, including reviewing project plans and providing input on staffing needs.
• Engages regularly with Medicaid market leaders to provide updates, gather feedback, and ensure there are no gaps or misalignments.
• Provides guidance on potential impacts across people, process, and technology related to DSNP implementation.
• Leads or supports cross-functional workgroups to address DSNP-specific operational needs.
• Assists with governance and quality-related items such as QIE/QIC reporting and issue resolution.
• Liaison for the DSNP PAL.
• Acts as a strategic partner ensuring operational readiness and alignment for a successful DSNP launch and sustainability.

Use your skills to make an impact.

Requirements

• Bachelor's degree or equivalent experience
• 5+ years of previous clinical experience in utilization management
• 2+ years of indirect or direct leadership experience
• Comprehensive knowledge of Microsoft Office applications including PowerPoint, Word, Excel, and Outlook
• Knowledge of regulatory requirements and National Committee for Quality Assurance (NCQA) standards

Preferred Qualifications

• Registered nurse (RN) with unrestricted licensed OR independent licensed clinical social worker (LCSW)
• Master’s degree
• Knowledge of Medicaid regulatory requirements
• Experience with contracting, audit, risk management, or compliance

Additional Information

• This position is open to work remote.

Work at Home Criteria: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Of