Become a part of our caring community and help us put health first
 

Humana is a $90 billion (Fortune 40) market leader in integrated healthcare with a clearly defined purpose to help people achieve lifelong well-being. As a company focused on the health and well-being of the people we serve, Humana is committed to advancing the employment experience and vitality of the associate community. Through offerings anchored in a whole-person view of human well-being, Humana embraces a focus on stimulating positive individual and population changes while nurturing a sense of security, enabling people to live life fully and be their most productive.

Against that backdrop, we are seeking an accomplished healthcare leader for the newly-created role of Director, Physician Leadership. In this role, you will be a key enterprise leader, with responsibility for evolving Humana’s Utilization Management of medical review by physician or nurse, with a focus on our 5+ million Medicare members. You will also facilitate the delivery of high quality, appropriate, and consistent clinical decision making to ensure appropriate outcomes and drive better quality health outcomes for our members.

To succeed in this position, you will need to be well versed in CMS knowledge of outpatient, inpatient, behavioral health and appeal criteria including regulation and policies. You much also be passionate about collaborating and partnering across the enterprise (e.g., with Clinical Operations, Markets, Care Management, Analytics, Pharmacy, etc.) to develop discrete, high-value strategies and to ensure execution of those strategies. And finally, you must driven by sustainably improving health outcomes for some of our most vulnerable members.

The Director, Physician leadership will lead Medical Directors performing utilization management for Medicare inpatient and behavioral medicine case types. This position can be located anywhere within the lower 48 states. 

Key Responsibilities:

• Lead an operational team of Medical Directors to review authorizations and ensure clinical decision-making skills that align to internal policy and CMS regulations.
• Establish key metrics of success for this and operational progress against them. Metrics should be inclusive of quality, access, and financial metrics, such as medical trend reduction and administrative costs.
• Collaborate with partners across the enterprise to develop, articulate, implement, evaluate, and refine a set of strategic initiatives that address, but are not limited to, the following domains:
  • Access: Ensure Humana members have fair and consistent authorization review and ability to appeal and have justification for the clinical decision.
  • Analytics and Measurement: Measurement to improve our ability to identify trends, highlight areas for improvement for star measure, establish tactics for advancing outcomes, and evaluate the impact of our strategic initiatives. Work collaboratively with enterprise teams to evaluate and synthesize data to inform clinically appropriate and advance the health outcomes of our members.
• Outcomes: Characterize the impactable drivers of prior authorization and Success in driving consistent and quality outcomes for our members.
• Internal Operations and Technology: Support efforts to improve the efficiency of health plan operations (utilization management and provider clinical contracting) to reduce friction for members, providers, and associates.
• External Partnerships: Explore, evaluate, and implement novel partnerships—with national and community-based organizations—that will expand Humana’s ability to impact health outcomes.
• Innovation: Support health innovation including increasing access to virtual and specialty care.
• Establish and maintain external relationships to ensure awareness of leading-edge innovation and policy changes in CMS clinical outcomes; represent Humana and Humana’s UM health strategy in external venues

Use your skills to make an impact
 

Required Qualifications

• The ideal candidate will have extensive healthcare industry experience (typically 5+ years) or related experience leading the development and implementation of complex strategic and/or operational initiatives.  He/she will understand the UM CMS ecosystem—including gaps and opportunities to improve the value and quality of care—especially for seniors.  In addition, this person will demonstrate leadership effectiveness and ability to design and implement constructive change within an organization and across multiple organizations.  Medical Doctorate Degree with unrestricted up to date certification and up to date board certification in a US recognized medical discipline.

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