[Remote] Medicaid Regional VP, Health Services at Humana

Louisiana, United States

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Not SpecifiedCompensation

Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, MedicaidIndustries

Requirements

8 or more years of management experience
Must live in Louisiana and have a current/unrestricted Louisiana medical license (willing to obtain licenses as required for various states in region)
Preference to be located in Baton Rouge (second preference New Orleans)
MD or DO degree
Board Certified in an approved ABMS Medical Specialty
Excellent communication skills
5 years of established clinical experience
Knowledge of the managed care industry including Medicare, Medicaid, and/or Commercial products
Possess analysis and interpretation skills with prior experience leading teams focusing on quality management, utilization management, discharge planning, and/or home health or rehab
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Preferred Qualifications
Medical management experience, working with health insurance organizations, hospitals and other healthcare providers, patient interaction, etc
Internal Medicine, Family Practice, OBGYN, Geriatrics, Hospitalist, ER, PM&R clinical specialists
Master's Degree

Responsibilities

Create and oversee clinical strategy for the region, relying on medical background and in-depth understanding of organization capabilities across segments/enterprise-wide
Provide medical leadership and strategy for Health Services Operations with fiscal responsibility for trend management
Oversee regional utilization management and case management for inpatient cases (acute care hospital, LTAC, Acute rehab, SNF) according to the Humana Medicaid Model of Care
Participate in Quality Operations including chair Quality Management Committee, complete initial peer review on quality of care complaints, complete peer-to-peer written and verbal communications
Oversee administrative budget for regional HSO & Quality Improvement including approve/deny expense reports & requisition requests for department members
Oversee Quality Improvement and HEDIS/STARS metrics improvement with PCP offices and IPAs
Participate in regional level committees and meetings setting medical necessity strategies
Provide oversight and direction for the implementation of regional clinical programs and strategies, as well as developing and implementing market level strategies
Manage internal operational/functional relationships related to profitability
Assist with network development and provider contracting with various providers and ancillary providers
Serve as clinical liaison with inpatient facilities and joint operating committees to maintain facility relationships and problem solve; especially reviewing contracts as to clinical services
Well-versed on financial aspects of various levels of risk bearing contracts and possess the ability to gain traction and adoption of the providers
Ability to thrive in a highly matrix environment

Skills

Utilization Management

Case Management

Quality Management

HEDIS

STARS Metrics

Peer Review

Budget Management

Provider Contracting

Network Development

Risk Bearing Contracts

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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