Utilization Management Strategy Lead

Become a part of our caring community and help us put health firstThe Clinical Strategy team is a multi-disciplinary team focused on creating data-driven strategies to transform our business and the experiences we create for our members, provider partners & associates. We partner closely with our operations counterparts, working hand-in-hand to translate these strategies into concrete roadmaps that will generate tangible value for all stakeholders.Within the Utilization Management (UM) Strategy team, our goal is to enable members to receive effective, appropriate care in a timely manner all while streamlining processes for our provider partners and reducing unnecessary costs from the healthcare system. The Utilization Management Strategy Lead role works closely with internal and external stakeholders, such as clinical operations, markets, provider contracting, analytics to identify opportunity areas, set priorities, design and execute initiatives, monitor results, and communicate findings and recommendations.This role would be a great fit if

You are passionate about Utilization Management - you're motivated by driving positive health outcomes for members and reducing waste in the healthcare system

You are driven - you're eager to use your strong strategic and analytical acumen to drive impact and create significant measurable value

You are collaborative- you like partnering across the enterprise to develop pragmatic, high-value strategies and drive exceptional execution of our key objectives

You are curious - you enjoy connecting the dots between business metrics and frontline, understanding key root causes for what we see in data, testing hypotheses for what we could improve to drive value, and transforming ideas into action

As the Utilization Management Strategy team, our mission sits at the intersection of members, provider partners and associates. We seek to (1) ensure members receive safe, high-quality and cost-effective care in a timely manner, (2) create best-in-class experiences for members and providers, (3) achieve these outcomes while driving operating efficiency.The Utilization Management Strategy Lead will bring deep expertise in utilization management (i.e., across in-patient and out-patient clinical services, end-to-end UM processes, cost of care levers, etc.). They will use their deep knowledge of UM and strategic mindset to help identify new opportunity spaces where we can better support members while improving cost of care. They will expedite UM Strategy initiatives by making informed recommendations based on UM clinical and/or operational experience, enabling prioritization of highly valuable and feasible initiatives and support implementation based on their subject matter expertise.Example projects include, but are not limited to: identifying ways to reduce waste in key clinical categories, optimizing prior authorization requirements to streamline processes for providers, ensuring members receive the most cost effective care, advising broader UM-related strategy initiatives with subject matter expertise.The UM Strategy Lead will:

Combine their analytical mindset and UM experience to identify the greatest opportunity to improve clinical outcomes for members, manage cost of care, and/or improve stakeholder experience

Lead efforts to explore novel approaches in managing cost of care in specific clinical categories

Work hand-in-hand with Clinical Strategy, Clinical Operations, Claims, Markets to shape new initiatives, providing input on best practices, viability, feasibility based on past UM-related experience

Work directly with cross-functional partners across the enterprise (such as clinical operations) to create the execution model and roadmap to capture prioritized opportunities

Monitor progress and performance of initiatives using key performance indicators (KPIs) and metrics

Report on the results of initiatives to senior leadership and stakeholders using clear and concise presentations

Stay updated on the latest trends, developments, regulations, standards, policies related to UM in the healthcare industry

Use your skills to make an impactRequired Qualifications.

Bachelor's degree in health care administration, public health, statistics, economics, or a clinical field with 6+ years of experience OR Master's level degree with 4+ years of experience in driving and creating strategy and/or operations experience

Past experience working in a utilization management role (e.g., clinical policy development, prior authorization requirement definition, prior authorization and claims review, UM vendor management, analytics / reporting)

Knowledge of utilization and/or claims cost management concepts, principles and practices (e.g., prior authorization, medical necessity, provider payment integrity, waste and abuse, etc.)

Familiarity with various clinical terminologies and classifications (e.g., ICD10, CPT, HCPCS)

Preferred Qualifications :

Strong analytical, problem-solving, and critical thinking skills, with attention to detail and accuracy

Ability to interpret and leverage data to improve strategy, drive insights and make recommendations

Strong written & verbal communication, presentation and interpersonal skills - ability to flex to different audiences, including senior leadership, and to convey complex information in a clear and concise manner

Track record of success leading through ambiguity, including structuring complex problems, reprioritizing as needed

Experience working with multi-disciplinary teams and influencing others (e.g., actuaries, statisticians, operational leaders and clinicians)

Ability to work both independently and collaboratively in a fast-paced and dynamic environment, with multiple priorities and deadlines.

Competency with Microsoft Office suite (PowerPoint, Excel)

Additional Information:Interview Format : As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.SSN Statement: Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana's secure website.WAH Statement : To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggestedSatellite, cellular and microwave connection can be used only if approved by leadershipEmployees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA informationScheduled Weekly Hours40Pay RangeThe compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$112,400 - $154,900 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.Description of BenefitsHumana, Inc. and its affiliated subsidiaries (collectively, 'Humana') offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.About usHumana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.Equal Opportunity EmployerIt is the policy of  Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or because he or she is a protected veteran. It is also the policy of  Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=HumanaWebsite.