Clinical Pharmacist Lead in Nationwide

Become a part of our caring community The Clinical Programs Pharmacist Lead will be a part of a collaborative Pharmacy Stars team which is accountable for Humana’s Stars patient safety measure performance. The Clinical Pharmacist Lead autonomously develops, implements, and manages clinical program strategies to improve Medicare members' medication adherence and appropriate medication use. The Clinical Pharmacist lead exercises independent judgment and decision making on complex issues regarding job duties and related tasks, works under minimal supervision, and analyzes variable factors to determine the best course of action. Use your skills to make an impact Required Qualifications Degree of Doctor of Pharmacy (PharmD or RPh) from an accredited School of Pharmacy Active, unrestricted pharmacy licensure 5+ years of clinical experience in managed care or pharmacy related field, or equivalent Proficient in Microsoft Office applications (especially Word, Excel, and PowerPoint) Excellent written and oral communication skills Thrives in a fast paced, multi-project work environment while still ensuring attention to detail Successful track record in facilitating and consulting across teams and managing projects Strategic thinking and planning capabilities, organized, and detail-oriented Ability to learn quickly, work under pressure and timeline, work with ambiguity, and make complex decisions as necessary to meet business need Ability to assimilate, analyze, draw conclusions, and make recommendations from complex data Preferred Qualifications Previous experience in Medicare Stars Managed care and/or community pharmacy experience or residency/fellowship Previous experience in clinical program development and leader

Become a part of our caring community The Medical Director, National Outpatient Medicare leverages clinical expertise and medical judgment to review preauthorization requests for services. This role is responsible for evaluating moderately complex to complex cases, where analysis of clinical information and situational factors requires in-depth assessment and sound decision-making. As a Medical Director at Humana , you will use your clinical expertise and judgment to make meaningful coverage and care determinations that support quality, consistency, and compliance across the healthcare continuum. In this role, you will review requests for services, level of care, and site of service, using nationally recognized clinical guidelines, CMS policies, medical references, and internal clinical resources to guide decision-making. This position offers the opportunity to work on complex outpatient cases , review clinical documentation, and collaborate with both internal partners and external physicians to gather additional information and discuss determinations. You may also contribute to care management activities and, depending on the role, provide input on areas such as clinical documentation, coding, grievances and appeals, and outpatient services or equipment reviews. Beyond case review, this role provides the opportunity to build strong relationships with physicians, provider groups, facilities, and community partners in support of regional priorities. It is a strong fit for physicians who are interested in contributing to value-based care, population health, and care management strategies while working in a structured environment that values sound clinical judgment, collaboration, and operational excellence. Humana is seeking a Medical Director to

Become a part of our caring community The Grievances and Appeals Representative 4 role in the Internal Review Team is responsible for managing appeal denials, by reviewing clinical documentation, determining whether further action is needed, and validating final determinations in coordination with clinical and internal Humana partners. Key Responsibilities: Manage Level 1 appeal cases , ensuring accuracy, completeness, and compliance with CMS requirements Review clinical documentation to support appeal determinations and escalation decisions Coordinate with clinical teams and internal partners to finalize appeal outcomes Investigate and resolve member and provider issues with a focus on timely resolution Maintain high productivity and quality standards in a production-driven environment Ensure strict adherence to confidentiality and compliance regulations Independently prioritize and manage multiple high-volume case assignments Proactively embraces change and supports smooth transitions in a dynamic work environment Use your skills to make an impact Required Qualifications: 1+ year of grievance & appeals and/or customer service experience Strong data entry skills Proficiency in Microsoft Office Applications Experience in a production-driven environment Experience prioritizing and delivering multiple assignments Strong commitment to confidentiality and high-quality results Preferred Qualifications: Associate's or Bachelor's degree 2–4 years of grievance and appeals experience Medical claims processing experience Previous inbound call center experience Experience wi

Become a part of our caring community As a Care Management Support Assistant, you will help members take the next step toward better health and well-being. You will do this by connecting with them over the phone, completing important non-clinical assessments, identifying barriers to care, and helping them access resources and benefits. We are looking for people who show compassion and document customer issues in detail, can work in a call center environment, and motivate themselves through work that directly supports members and care teams. This is a remote position, and the assigned shift will be 11:30 AM–8:00 PM Eastern Standard Time. Job Description What You Will Do Engage members by phone to encourage participation in care management programs. Complete required assessments and questionnaires to help identify health risks, care needs, and opportunities for clinical team follow-up. Assist members who need support scheduling doctor’s appointments or connecting with appropriate care resources. Identify and help address barriers to preventive screenings, benefits, and health-related services so members can close gaps in care. Support members in understanding, retaining, and accessing benefits that contribute to their overall health and well-being. Manage both inbound and outbound calls in an auto-dialer environment while documenting member information. What Success Looks Like You create a positive member experience by treating each interaction with respect, patience, and professionalism You demonstrate compassion, integrity, and sound judgment when supporting members with sensitive health-related needs You listen to

Become a part of our caring community Humana’s Quality and Cost Strategy Analytics Team is seeking a Research Scientist 2 (Remote). Healthcare is rapidly changing, and our members are living longer, often with more chronic conditions. The Quality and Cost Strategy Analytics team identifies opportunities and build solutions to improve clinical outcomes and lower costs for millions of Medicare Advantage beneficiaries leveraging data science & analytics, clinical expertise, strategic mindset, and rigorous study designs. In this multi-disciplinary team, you will have the opportunity to work closely with strategy partners and clinicians to shape Humana’s future enterprise clinical strategies and initiatives. The Research Scientist 2 will lead research, evaluation and development of opportunities that optimize healthcare delivery, lower medical cost while improve member health outcomes, through applying mathematical, statistical, epidemiologic and data science methods. The Research Scientist 2 will also partner with stakeholders across the enterprise to identify, prioritize and measure the impact of core and novel solutions to significant problems in healthcare and improve the health of especially underserved population, using high volumes of structured and unstructured data. Responsibilities As a Research Scientist 2, you will: Research, prototype and scale new ideas to improve population health and healthcare delivery Collaborate with analytic and business teams to set objectives, approaches, and work plans Collaborate with strategy to evaluate existing programs and identify and measure new solutions to impact healthcare Leverage a wide range of analytics methods ranging from descriptive to prescriptive to transform high volumes of complex data into analytics solut

Become a part of our caring community The Financial Analytics Professional 2 manages data to support and influence decisions on day-to-day operations, strategic planning and specific business performance issues. The Financial Analytics Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. The Financial Analytics Professional 2 collates, models, interprets and analyzes data in order to identify, explain, influence variances and trends. Explains variances and trends in clinical and financial data and enhances modeling techniques to improve forecast accuracy. May possess financial or actuarial background. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures. Use your skills to make an impact Required Qualifications Bachelor's Degree 1&#43; years SQL and Python experience Microsoft Office (Excel, Power BI, etc.) Experience in compiling, modeling, interpreting and analyzing data in order to identify, explain, influence variances and trends Explain variances and trends and enhance modeling techniques Experience in managing data to support and influence decisions on day-to-day operations, strategic planning and specific business performance issues Must be passionate about contributing to an organization focused on continuously improving consumer experiences Preferred Qualifications Business Intelligence, Financial, or Actuarial background Azure Databricks experience</

Become a part of our caring community Services represent one of the organization’s most consequential sources of capability, capacity, transformation and external spend. The Associate Vice President, Services Procurement will lead the enterprise strategy for contingent workforce, outsourcing and offshoring, consulting and clinical services, converting third-party services into measurable business outcomes, workforce agility, operating leverage and sustainable value. The AVP will serve as the senior Procurement partner to leaders across the Insurance segment and Corporate Services, helping shape operating-model, workforce and transformation decisions before sourcing begins or a supplier solution is selected. The leader will bring deep expertise in global business services, business process outsourcing, workforce solutions and complex professional services. The mandate is to strengthen business-case quality, establish clear make, buy, build, automate and partner choices, create fit-for-purpose commercial models, manage transitions and hold providers accountable for committed outcomes. Success will be measured by whether business leaders make better services and workforce decisions, transformations deliver their promised value, and suppliers improve performance and innovation. Key Responsibilities Serve as the Strategic Services Partner to Business Leaders Serve as the senior Procurement relationship leader and trusted commercial advisor to Insurance segment and Corporate Services leadership. Develop a deep understanding of business strategy, operating plans, transformation roadmaps, workforce needs and financial commitments, and translate them into integrated services, workforce and supplier strategies. Engage upstream of supplier selection to frame the problem, test demand and assess make, buy, build, automate, offshore, outsource

Become a part of our caring community The Market Finance Lead is a key member of the Gulf South Region’s finance team responsible for connecting market financial performance with operational effectiveness. This role will partner closely with Corporate Finance, Network Performance, Network Contracting, and regional Health Services teams. This individual will manage a team covering a diverse set of responsibilities around Medicare Advantage financial business operations with a heavy focus on value-based providers. This role reports to the Market Finance Director. This role analyzes financial results, claims experience, utilization trends, contract performance, membership, and provider performance data to identify opportunities, influence business decisions, and support market growth and operational improvement. The Market Finance Lead will partner closely with regional leadership, actuarial, corporate finance, clinical, risk adjustment, market operations, network performance, network contracting, sales/MarketPoint, and value-based care providers. This individual will translate complex financial and operational data into meaningful insights, recommendations, and action plans that improve performance across the market. As the Market Finance Lead, you will: Manage a team to review value-based providers’ financial performance, membership, cost and utilization trends, contractual results, and opportunities for improvement. Lead the financial portion of provider engagement prep sessions prior to joint operating committee meetings to advise the Network Performance team on contract performance and opportunities for improvement. Lead analysis and reporting related to value-based provider and contract performance, including financial results, utilization, claims experience, membership, and operational trends. Leverage data analytics, business ins

Become a part of our caring community Provides executive leadership to Humana. The Regional Chief Medical Officer (CMO) is an entrepreneurial & experienced physician leader committed to the principles of comprehensive primary care and unlocking the power of value-based care for patients at national scale. S/he will be a proven clinician, leader, and strategist capable of driving the highest standards of care, building high-performance care teams, developing clinical leadership talent, and quantifiably improving outcomes and performance across multiple geographies. The Regional CMO will directly lead a team of regional & area medical directors and serve as dyad partner to the Regional Market President for one of the Primary Care Organization’s regions across the nation where CenterWell and/or Conviva serve patients. The Regional CMO will report to the Chief Medical Officer of the Primary Care Organization. This role requires periodic travel to markets (40% or less) to meet with national and regional teams and should be based in one of our current or upcoming CenterWell or Conviva markets. Responsibilities Drive Clinical Excellence in Culture & Performance · Build a best-in-class culture of engaged clinicians, focused on patient-focused care and clinical excellence, where doing the right thing for patients and team-based care within a value-based care framework, drives success and pride · Drive patient outcomes and population impact across regions for optimal results, across patient care experience & engagement, disease prevalence, quality/STARS, efficiency of care, and improved clinical outcomes and utilization. · Identify and act on opportunities

Become a part of our caring community The Associate Vice President, Model & AI Governance, is the enterprise leader responsible for establishing and overseeing the organization’s framework for model governance, artificial intelligence (AI) risk management, responsible AI and AI governance. Reporting to the Chief Audit & Risk Officer, this executive provides independent second-line oversight and challenge of the organization’s use of models, advanced analytics, machine learning, generative AI, and emerging AI technologies. The role establishes the governance, risk-management, control, monitoring and escalation framework necessary to ensure AI models are deployed in a manner that is safe, ethical, transparent, explainable, compliant, secure and aligned with the organization’s mission and risk appetite. The Associate Vice President, Model & AI Governance, partners closely with executive leadership, technology, data and analytics, clinical/business leaders, compliance, legal, privacy, cybersecurity, information security, internal audit, enterprise risk management and other control functions to ensure AI-related risks are identified, assessed, governed, monitored, and appropriately reported. This leader will serve as an advisor to executive management on emerging model and AI risks, while maintaining appropriate independence from the teams developing and deploying models and AI solutions. Key Responsibilities Own and continuously enhance the enterprise model governance framework, including model identification, inventory, classification, risk tiering, development, validation, approval, implementation, monitoring, change management, retirement and documentation. Define model risk appetite, risk taxonomy, minimum control standards, governance requirements and escalation thresholds. Provide effective challenge over model