Note: The job is a remote job and is open to candidates in USA. Humana is a leading U.S. healthcare company, and they are seeking a VP of Medicaid Clinical Operations. The role is responsible for leading Medicaid clinical operations, ensuring operational excellence, and translating Medicaid strategy into standardized operating models and measurable performance outcomes.
Responsibilities
- Lead Medicaid Clinical Operations, including clinical and nonclinical teams supporting utilization management, care management/service coordination, program operations, process improvement, training, and project execution
- Establish clear operating rhythms, accountability structures, workforce productivity expectations, and performance management processes across distributed clinical operations teams
- Build and sustain an engaged, high-performing leadership culture focused on associate development, retention, operational discipline, and measurable outcomes
- Develop and execute Medicaid clinical operations strategies that support growth, market expansion, state contract requirements, enterprise priorities, and scalable operating model transformation
- Translate clinical strategy, market commitments, and program designs into operational workflows, staffing models, performance targets, and implementation plans
- Lead operational readiness and implementation for new Medicaid markets, expanded programs, and enterprise transformation initiatives
- Drive standardization, workflow optimization, and continuous improvement to improve scalability, consistency, and performance across markets
- Oversee Medicaid utilization management and care management/service coordination functions, ensuring consistent clinical practices, regulatory compliance, timely decision-making, and appropriate escalation management
- Advance integrated care models that address physical health, behavioral health, long-term services and support, social needs, and complex population health needs
- Strengthen care navigation, member access, provider coordination, and interventions that reduce avoidable utilization and improve health outcomes
- Partner with physician leadership, nursing leadership, behavioral health, quality, market, Medicare, and functional teams to align clinical programs and support dual-eligible and complex member populations
- Partner with Product, Technology, Data, Analytics, and Operations teams to translate Clinical Operation’s needs, regulatory requirements, workflow gaps, and performance priorities into clear business requirements, use cases, and solution expectations
- Provide clinical operational input into technology roadmaps, solution design, workflow enablement, reporting needs, user adoption considerations, and post-implementation performance feedback
- Ensure technology-enabled solutions support standardized clinical workflows, accurate reporting, operational scalability, associate effectiveness, care coordination, and measurable clinical operations outcomes
- Establish, monitor, and improve key performance metrics, including quality, compliance, cost of care, access, utilization, productivity, service levels, member experience, provider experience, revenue, margin, and client or contract performance commitments
- Partner with Finance to manage budgets, staffing models, labor efficiency, investment priorities, and operating performance
- Identify performance gaps, assess clinical and operational risk, and implement mitigation plans, corrective actions, and sustainable performance improvement routines
- Serve as a key escalation and decision authority, providing clarity, prioritization, and direction during periods of ambiguity, change, or operational risk
- Partner with Medicaid markets, Medicare, Quality, Compliance, Legal, Finance, Product, Technology, Analytics, Provider, Behavioral Health, LTSS, and enterprise operations teams to deliver integrated clinical outcomes and ensure operational needs are reflected in enabling capabilities
- Serve as a key liaison for Dual Eligible Special Needs Plan alignment, Medicaid-Medicare coordination, annual plan lifecycle needs, and cross-functional stakeholder engagement
- Guide partnerships with providers, home and community-based services organizations, vendors, and other external partners to support member-centered, high-quality care delivery
- Represent Medicaid Clinical Operations in executive forums, business reviews, client or state-facing discussions, transformation governance, and performance reviews
- Drive consistent, high-quality clinical operations across Medicaid markets while enabling growth, innovation, operational excellence, and regulatory readiness
- Advance whole-person, integrated care for Medicaid members by connecting strategy, clinical expertise, analytics, operating discipline, and effective cross-functional partnership
- Develop a strong clinical operations leadership pipeline and culture of accountability, collaboration, engagement, and continuous improvement
Skills
- Bachelor's degree required
- 10 plus years of progressive experience in Medicaid, managed care, clinical operations, utilization management, care management, population health, health services operations, or healthcare transformation
- 5 plus years leading large, distributed clinical and/or operational teams, including leaders of leaders, through scale, change, and performance improvement
- Deep understanding of Medicaid programs, state contract requirements, regulatory expectations, integrated care models, LTSS, behavioral health, complex populations, and DSNP coordination
- Demonstrated ability to translate strategy into operational execution, standardized workflows, measurable outcomes, and sustainable performance improvement
- Strong financial acumen, including experience managing budgets, staffing models, productivity, labor efficiency, revenue, margin, and operating performance
- Proven ability to lead through ambiguity, influence cross-functionally, manage risk, engage senior stakeholders, and communicate effectively with executive audiences
- Advanced degree in nursing, public health, healthcare administration, business administration, social work, or a related field preferred
- Clinical license, nursing degree, or other healthcare credential; MD is not required
- Experience partnering with Product, Technology, Data, and Analytics teams to translate clinical operations needs into business requirements, workflow priorities, reporting needs, user adoption considerations, and measurable solution outcomes preferred
Benefits
- This position is remote.
- Occasional travel to Humana's offices for training or meetings may be required.
Company Overview
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