VP, Physician Review and Market Insights

Humana • Washington, DC • 2h ago

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Provides executive leadership to Humana.

The Chief Medical Officer, Utilization Management (UM) will serve as the clinical strategist, operator, and visionary for Humana's Utilization Management organization. This executive role is responsible for integrating and overseeing all Outpatient and Inpatient based MDs and RNs and non-clinical support for UM functions in Medicaid and Medicare, with a focus on streamlining processes, ensuring consistent clinical practices, driving trend savings, improving Star Ratings, and enhancing operational efficiency. The CMO, UM will ensure alignment with Humana's strategic objectives and enterprise operating model.

Use your skills to make an impact

Key Responsibilities:

Set clinical strategy and lead the Utilization Management organization. Oversee the integration of medical doctors and registered nurses in UM across Medicaid and Medicare. Provide leadership in risk management, grievance and appeals, clinical contracting, vendor management, and UM dental review. Ensure the clinician's perspective is central to organizational decision-making. Leverage analytics to inform strategy and performance improvement. Sponsor the development of clinical talent and leadership pipeline.

Organizational Scope:

The Chief Medical Officer, UM leads a significant functional organization, with direct accountability for human capital and organizational performance.

Direct reports include:

VP, Physician Leadership

Clinical contracting, physician review, quality improvement, legal MDs

Director, Physician Leadership

MD vendors, grievance and appeals

AVP, UM Nursing

UM RNs (transplant, behavioral health, appeals, etc.)

Lead Dental Director

Dental MD/RN review, bid season benefit review

Director, Strategy Advancement

Market liaison, provider/facility relationships

AVP, UM Administration

UM intake, vendor management, administrative support

Role Impact:

Drive the formation, execution, and sustainability of Humana's Utilization Management strategy. Challenge the healthcare status quo to improve quality, Star Ratings, and health outcomes. Integrate evidence-based approaches for UM reviewers. Support Humana's commitment to whole-person health and consistent, high-quality outcomes.

Candidate Qualifications:

MD/DO

Current Board Certification

Minimum 10 years of combined leadership and/or UM experience.

Passion for improving Star Ratings, review consistency, and health outcomes. Deep knowledge of medical, clinical, and behavioral science underpinning UM. Strong interpersonal, leadership, and business acumen. Proven ability to drive cross-functional results and champion clinical perspectives.

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

Scheduled Weekly Hours

Application Deadline: 06-25-2026

About us

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.

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. 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.

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