Senior Policy Governance Professional - Remote Eligible

Senior Policy Governance Professional

The Senior Policy Governance Professional will focus on compliance processes and execution within the organizational structure. The Senior Policy Governance Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Desired Senior Policy Governance Professional will facilitate the implementation of the enterprise framework and document consistent clinical decision making. This includes appropriate monitoring of controls, identifying opportunities and collaborating with internal partners to address identified gaps. They will work closely with established functions inside utilization management (Medical Director, clinician decision making teams, quality audits, prior authorization list and clinical policy) as well as enterprise support teams (process, risk, strategy, delegate oversight teams and regulatory compliance). As needed, facilitate MD to MD discussions to support education and awareness of enterprise standards for application of UMC approved clinical criteria. As appropriate works closely with Clinical Risk Management to support enterprise MD speaker readiness for external audits or other inquiries.

Specific responsibilities:

• Monitor enterprise controls based on the established pillars for consistent clinical decision-making: self-identification, quality oversight and monitoring, calibration on criteria, and continuous process improvement.
• Develop and adhere to framework processes.
• Educate stakeholders on expectation for clinical decision making.
• Interface with established controls provided by quality audit, clinical policy, process policy/documentation and reporting teams.
• Monitor thresholds and identify appropriate actions when controls indicate process gaps.
• Review appeal overturns and provider complaints about coverage policies to make necessary changes.
• Drive continuous process improvement including supporting UM strategic initiatives.
• Identify potential gaps between the intended application of coverage policies versus the actual application of clinical reviewers.
• Recommend enhancements to the coverage policy template to help ensure consistent and accurate interpretation and application of coverage policies.
• Support decision template development process to help ensure that templates aligned with coverage criteria and regulatory and accreditation requirements.

Center of excellence and support for requirements and expectations for UM Delegates and internal partners:

• Proactively identifies potential risks and impacts to UM delegates based on Humana Business Decisions.
• Manages Humana-to delegate discussions for consistent clinical decision making.
• Ensures business decisions.
• Support Delegation Compliance, delegate business relationship owners, strategy teams and National delegate oversight and support team on UM issues.
• Evaluates available data on delegate clinical decision-making and partners with clinical risk and regulatory compliance to evaluate specific action to mitigate detected risk.
• Supports PAL/clinical policy intake processes when there is malalignment with PAL codes and clinical policy changes.

Developing and overseeing the plan for MD speaker engagement in CMS program audits:

• Work closely with Clinical Risk Management for documentation of roles, RACI and expectations for MD audit engagement.
• Drive enterprise discussion to decide on MD leadership and coordination for MD participation in CMS audits.
• Gain segment leadership alignment for plan and expectations when prepping for CMS program audit.
• Managing the CMS Audit speaker organization and readiness preparation.
• Support Humana MD participants with onboarding and engagement in rehearsals.
• Develop framework for supporting delegate audit readiness, coordinate with Delegation Compliance.
• Support large clinical vendor delegates with onboarding and engagement in rehearsals and defense in the CMS program audit.

Use Your Skills to Make an Impact

Required Qualifications:

• Registered Nurse
• 2+ years + experience working with CMS Compliance Regulations
• Experience working with medical directors in some capacity i.e. Committees, projects.
• 3 or more years' Utilization Management Experience
• 2 + years of project leadership experience
• Persuasive, collaborative business acumen with the ability to influence others
• Executive presentation skills and ability to communicate with all levels
• Strategically oriented, resourceful, influential, critical thinker with strong problem-solving skills
• Ability to identify actionable insights from large data sets and translate them into strategies and secure buy-in through excellent written and verbal communication

Preferred Qualifications:

• Project Management Professional (PMP) certification
• Six sigma certifications
• Experience in an audit or compliance role for a Health Plan or provider-based industry
• Knowledge and experience in health care/managed care regulatory environment

Additional Information:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; 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.

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.

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.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours 40

Pay Range $86,300 - $118,700 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.

Application Deadline: 08-28-2025

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.

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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements.