Clinical Investigation Lead

Humana - Trenton, NJ

Full-time - Senior

Remote - Trenton, NJ

Insurance Carriers and Related Activities

About the position

The Clinical Investigation Lead at Humana is a pivotal role within the Clinical Strategy Team, focused on leveraging advanced analytics and clinical expertise to enhance healthcare delivery. This position aims to reduce waste and overuse of healthcare services while promoting high-value care. The lead will analyze complex clinical and operational data, collaborate with various stakeholders, and drive initiatives that improve member experiences and health outcomes.

Responsibilities

• Support enterprise-wide initiatives to address healthcare waste and inappropriate care.
• Collaborate with cross-functional partners to investigate early indicators of inappropriate spend and identify clinical opportunities.
• Generate actionable business insights through detailed investigations leveraging analytics, research, and clinical acumen.
• Lead project workgroups with operational teams and enterprise partners to vet and implement prioritized solutions.
• Produce high-quality presentations and reports for diverse stakeholders.

Requirements

• 7+ years of experience in clinical strategy and/or HealthPlan operations.
• Professional clinical license (e.g., MD, Registered Nurse, or Pharmacist) or advanced degree such as a Master's degree or higher in Epidemiology or Public Health.
• Experience in medical cost opportunity identification to improve evidence-based clinical care.
• Expertise in critically reviewing and synthesizing recommendations from clinical society guidelines and literature.
• Experience working with multi-disciplinary teams, with a deep understanding of healthcare data and health-systems operations.
• Excellent written and verbal communication skills, with the ability to present complex information to senior-level audiences.
• Strong analytic and trend skills.
• Proven ability to work collaboratively across teams and stakeholders.
• Engage in ambiguous problem solving and strategy setting.
• High learning acuity and ability to navigate rapidly changing situations and business priorities.

Nice-to-haves

• Demonstrated experience working with healthcare claims data sets, including medical coding and medical claims.
• Experience with utilization management (UM) and regulatory guidelines.