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The Care Management Senior Risk Management Professional contributes to the success of Humana’s business strategy by supporting risk and compliance initiatives across the Care Management organization. They have responsibilities for Care Management CMS program audit readiness and coordination, state audit coordination, Care Management risk consulting, and development of Quality Improvement Evaluation reports.

As the Senior Risk Management Professional you will be responsible for identifying, assessing, and remediating risks, evaluating internal and external audit results, providing support for internal and external audits, and performing ongoing monitoring, assessment and communications regarding business risks with functions across the organization. The scope of responsibilities includes the following:

• Review CMS, NCQA, and state-based regulations; provide guidance to business owners on implementation of the requirements and validate effectiveness of the implementation.

• Assess processes, documentation, metrics, and data sets to identify operational and compliance risks/gaps; develop and oversee implementation of remediation activities.

• Work with operational leaders to ensure alignment between systems, internal/external reporting, operational processes, and monitoring and oversight procedures.

• Support internal and external audits: Lead data/universe preparation initiatives, review supporting documentation submissions, communicate audit findings to business owners, and work with impacted parties to implement remediation plans for issues identified.

• Issue and Opportunity Management reporting and oversight for Care Management, including the tracking and reporting of IOPS, enterprise reporting, action plan development and implementation, and serving as a liaison between the issue creator and business.

• Provide assurance around the effectiveness and efficiency of Care Management compliance and operational processes.

• Perform targeted reviews of processes, documentation, metrics, and data sets to identify strategic, operational and compliance risks/gaps; develop and oversee implementation of remediation activities.

• Work in partnership with multidisciplinary teams and key internal and external stakeholders to develop relationships and define business requirements.

• Serves as subject matter expert for Care Management program policies, process, and regulatory and/or contractual requirements.

• Lead meetings and prepare presentations, reports, and dashboards.

• Serve as a problem solver, provide recommendations, and implement change.

Succes in this role requires:

• Strong oral and written communication skills

• Strong critical thinking and problem-solving skills

• Heavy detail-orientation and effective organization skills

• Solid business acumen and understanding of how the business works

• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Use your skills to make an impact

Required Qualifications

• Bachelor's degree or 8+ years of commensurate work experience

• 5+ years’ experience with Medicare and/or Medicaid with knowledge of regulations governing health care industries

• 5+ years of experience with identifying and mitigating risks and improving business results

• Working knowledge of CMS Regulatory Guidelines

• Experience with the end-to-end audit process (audit preparation through issue resolution)

• Experience with monitoring, metric review and data validations

• Experience creating dashboards for data trending, and reporting

• Solid understanding of care management/care coordination operations, technology, communications, and processes

• Proficiency with all Microsoft Office applications with proficiency working in Outlook, Teams, SharePoint, Excel, PowerPoint, and Word

• Travel up to 15-20% (This is concentrated into 1-2 trips per year for on-site audits)

Preferred Qualifications

• Experience with Humana’s care management platforms

• Knowledge of Humana’s internal policies and procedures

• Proficiency querying and analyzing healthcare data

• Process development and implementation experience

• Project management/process management experience

• Experience with strategic initiatives and implementations

• Experience with Medicare and Medicaid contracts

Work-At-Home Requirements

To ensure Work-at-Home 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 interruptions to protect member PHI / HIPAA information

Additional Information

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.

Scheduled Weekly Hours

40

Pay Range

The 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.

$76,800 - $105,800 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, 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 us

Humana 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 Employer

It 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 veteran status. 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=Humana_Website.