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The Lead Clinical Implementation Consultant serves as the clinical subject matter expert responsible for translating utilization management requirements into consistent operational workflows and technology solutions. This role provides clinical leadership for enterprise initiatives by interpreting clinical requirements and ensuring they are accurately implemented across clinical decision support tools, electronic prior authorization, claims operations, and supporting technology platforms.Working collaboratively with Medical Directors, Referrals and Authorizations, Claims, Product, and Technology, this position ensures new clinical services, procedure codes, and utilization management requirements are implemented consistently throughout the organization while improving provider experience, operational efficiency, and clinical accuracy.
Our Government Contract Requires US Citizenship for this Position
KEY ACCOUNTABILITIES
Responsible for governance of new clinical procedure codes and ensuring those decisions are accurately and consistently implemented across systems and teams.
Lead key clinical technology solutions by serving as the business owner for CareWebQI and the clinical lead for ePA, partnering with Product and Technology teams to improve workflows and drive automation opportunities.
Connect Medical Directors, Claims, Referrals and Authorizations, Technology, and Product to support aligned decision-making and effective cross-functional collaboration and continuous improvement initiatives
Use your skills to make an impact
Required Qualifications
- Active, unrestricted Registered Nurse (RN) license.
- Bachelor's degree in nursing (Master's degree preferred).
- 7+ years of progressive experience in Utilization Management, Managed Care, Clinical Operations, or related healthcare operations.
- Applicable State licensure in field of study
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Preferred Qualifications
- Master's degree in nursing
- Experience with electronic prior authorization (ePA) solutions and industry interoperability standards. Specifically, MCG Cite AA
- Knowledge of NCQA, URAC, and other accreditation standards related to utilization management.
- Experience in managed care, health plan operations, or Medicare Advantage programs (including various SNP products) or Managed Medicaid.
- Familiarity with remote monitoring, digital health tools, or clinical innovation platforms.
- Project management experience or certification (e.g., PMP, Lean Six Sigma).
Scheduled Weekly Hours
40Pay 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.$104,000 - $143,000 per yearThis 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
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.