Senior Clinical Policy Research Professional

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Health InsuranceIndustries

Requirements

Candidates must possess a Bachelor of Science in Nursing (BSN) or a Bachelor's degree in any field, along with an active, unrestricted Registered Nurse (RN) license. A minimum of 5 years of clinical experience is required, demonstrating strategic thinking, planning capabilities, organization, and attention to detail. Proficiency in Microsoft Office, particularly Word and Excel, is essential, as is the ability to work independently, meet deadlines, and perform strong analytical and web navigation tasks. A Master's degree in a health- or business-related field and utilization management experience are considered desirable qualifications.

Responsibilities

The Senior Clinical Policy Research Professional will research and develop medical coverage policies using a standardized checklist and evidence-based medicine review processes. Responsibilities include providing comprehensive verbal and written research summaries to medical directors and leadership for various committees, performing ad hoc medical research for individual case reviews, and researching new CPT and HCPCS codes quarterly. The role also involves participation in interdepartmental committees and liaising with external entities such as medical device manufacturers and professional societies.

Skills

Clinical Policy Research

Evidence-Based Medicine

Medical Coverage Policies

Medicare

Medicaid

CPT codes

HCPCS codes

Registered Nurse (RN)

Strategic Thinking

Detail-Oriented

Written Communication

Oral Communication

Microsoft Office

Analytical Skills

Web Navigation

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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