VP, Physician Review and Market Insights
About The Position
Provides executive leadership to Humana. The Chief Medical Officer, Utilization Management (UM) will serve as the clinical strategist, operator, and visionary for Humana’s Utilization Management organization. This executive role is responsible for integrating and overseeing all Outpatient and Inpatient based MDs and RNs and non-clinical support for UM functions in Medicaid and Medicare, with a focus on streamlining processes, ensuring consistent clinical practices, driving trend savings, improving Star Ratings, and enhancing operational efficiency. The CMO, UM will ensure alignment with Humana’s strategic objectives and enterprise operating model.
Requirements
- MD/DO
- Current Board Certification
- Minimum 10 years of combined leadership and/or UM experience.
- Passion for improving Star Ratings, review consistency, and health outcomes.
- Deep knowledge of medical, clinical, and behavioral science underpinning UM.
- Strong interpersonal, leadership, and business acumen.
- Proven ability to drive cross-functional results and champion clinical perspectives.
- Self-provided internet service must meet at least a download speed of 25 Mbps and an upload speed of 10 Mbps; wireless, wired cable or DSL connection is suggested.
- Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Responsibilities
- Set clinical strategy and lead the Utilization Management organization.
- Oversee the integration of medical doctors and registered nurses in UM across Medicaid and Medicare.
- Provide leadership in risk management, grievance and appeals, clinical contracting, vendor management, and UM dental review.
- Ensure the clinician’s perspective is central to organizational decision-making.
- Leverage analytics to inform strategy and performance improvement.
- Sponsor the development of clinical talent and leadership pipeline.
- Drive the formation, execution, and sustainability of Humana’s Utilization Management strategy.
- Challenge the healthcare status quo to improve quality, Star Ratings, and health outcomes.
- Integrate evidence-based approaches for UM reviewers.
- Support Humana’s commitment to whole-person health and consistent, high-quality outcomes.
Benefits
- Humana insurance services
- CenterWell healthcare services
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What This Job Offers
Job Type
Full-time
Career Level
Executive
Education Level
Ph.D. or professional degree
