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The Utilization Management (UM) Director, Clinical Strategy and Practice for Medicaid builds strategies for development, engagement, best clinical practices and processes for clinical community within the enterprise. The Director, Clinical Strategy and Practice requires an in-depth understanding of how organization capabilities interrelate across the function or segment.

The Utilization Management (UM) Director, Clinical Strategy and Practice for Medicaid is responsible for leading the deployment of new markets, governance, and strategic development of Utilization Management (UM) processes and workflows across Medicaid markets. This role ensures consistency in structure, policies, and procedures while driving innovative solutions to enhance efficiency and outcomes in Medicaid UM. The position requires a strong focus on strategic planning, collaboration across departments, and a commitment to high-quality service delivery in a complex, multi-state environment. In this newly defined role, the Director, Clinical Strategy and Practice will also provide ongoing management and strategy support. This position will report directly to the Associate Vice President of Clinical Strategy and Practice for Medicaid.

Key Responsibilities

• Oversees deployment of Utilization Management (UM) processes and workflows for new Medicaid states.

• Oversee standardization of UM processes for existing Medicaid markets.

• Oversee operations of existing market centralization.

• Establish and maintain governance for UM structure, policies, and procedures across Medicaid states to ensure compliance and operational consistency.

• Drive implementation of new market initiatives, including processes and procedures to align with state and federal Medicaid requirements.

• Design and execute new workflows, processes, and strategies to improve outpatient UM operations.

• Develop strategic plans to streamline and enhance outpatient UM processes across Medicaid markets.

• Lead UM-related workstreams for Medicaid Requests for Proposals (RFPs), including mapping UM components for new state bids.

• Oversight and coordination of DSNP strategy and programs

Use your skills to make an impact
 

Required Qualifications

• Registered nurse (RN) with unrestricted licensed OR independent licensed clinical social worker

• 2-5 yrs of previous senior leadership experience in the healthcare industry

• 3+ years of experience in Medicaid or healthcare Utilization Management, with a focus on outpatient care.

• Proven expertise in process development, strategic planning, and program implementation.

• Innovative leader who can drive transformational initiatives, ensure operational excellence, and positively impact Medicaid utilization management outcomes.

• Excellent relationship-building skills and proven ability to work collaboratively through various departments and functional areas, promoting a culture of proactive teamwork. 

Preferred Qualifications

• Bachelor's degree

• Proven leadership experience Director Level and above.

• Strong leadership skills and ability to work effectively in a cross-functional, matrixed environment.

• 2+ yrs Payer experience with responsibility for the creation and ownership of strategies for a large business unit. 

• This person will also have a proven record of success in orchestrating the efforts of cross-functional colleagues in large-scale projects.

Additional Information

This position is open to work remote

Work at Home Criteria  

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 suggested.  

• Satellite, cellular and microwave connection can be used only if approved by leadership.  

• Employees 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 interru