VP, Clinical Policy and Risk Management

About the role

Become a part of our caring community. Humana maintains a robust clinical risk management function to ensure effective risk mitigation, control, and governance processes across Care Management and Utilization Management. The mission of the Medicare and Medicaid Operational Risk Management Department is to partner with CM/UM teams to drive operational compliance, member access to care, and efficiency, while proactively identifying and managing risks related to care and utilization management.

The Vice President, Clinical Policy and Risk Management will oversee a department comprising 7 direct reports and 250 associates that lead CM/UM Risk Management, UM and CM audit teams, and policy governance. This role reports directly to the Senior Vice President – Clinical Operations.

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.

Responsibilities

• Identify, assess, and report operational and clinical risks within CM/UM processes to appropriate governance structures.
• Monitor CM/UM compliance and operational metrics, ensuring escalation and resolution of any issues impacting member care or regulatory compliance.
• Track, interpret, and implement CMS Federal and Medicaid State regulations impacting CM/UM, ensuring timely and complete adoption.
• Support regulatory audits with emphasis on CM/UM compliance and facilitate remediation where necessary.
• Lead risk mitigation efforts related to care management and utilization management, including maturity assessments and oversight of issues and opportunities.
• Oversee CM/UM business continuity and work across leadership to resolve any IOPs administered.
• Foster quality and continuous improvement within CM/UM control processes, ensuring alignment with policies, standards, and applicable laws.
• Address legislative and regulatory issues with potential impact on CM/UM operations, including fraud risk identification and mitigation.
• Partner closely with Legal, Compliance, Regulatory Affairs, and business leaders to assess emerging regulatory and legal risks, interpret legislative requirements, support audit and litigation readiness activities, and ensure CM/UM policies, controls, and operational practices align with applicable federal and state laws.

Requirements

• Bachelor’s degree required; MBA preferred.
• Maintains an active, unrestricted clinical license in the applicable discipline (e.g., RN, LCSW, LPC, LMFT, PharmD, MD/DO, or other relevant clinical credential) and demonstrates the ability to apply clinical expertise, professional judgment, and regulatory knowledge to support business, operational, and member outcomes.
• Extensive experience (10+ years) in CM/UM risk management, regulatory compliance, process improvement, or related fields, with 6 plus years in leadership roles.
• Advanced knowledge of CM/UM operational controls, risk mitigation strategies, and regulatory requirements for Medicare and Medicaid.
• Demonstrated expertise in internal controls, clinical and operational risk management, and IT technical controls within CM/UM environments.
• Exceptional project management skills, integrity, and business ethics.
• Ability to collaborate with stakeholders across the enterprise and influence outcomes in complex, matrixed environments