Jobs at Humana

Leads regional financial and operational strategy for a Medicare health plan across Texas, Oklahoma, and Arkansas. Owns regional P&L, budgets, forecasts, margin and administrative targets, risk management, performance reporting, and the annual CMS Medicare Advantage bid process. Directs the regional Finance team and collaborates with provider network, health services, quality, product, and growth leaders. Oversees policy development, process improvements, provider performance analysis, and strategic relationships with physician and hospital leaders.

Leads enterprise provider performance strategy for Medicare Stars, including provider reporting, dashboards, quality improvement programs, incentives, data quality, governance, connectivity, and performance optimization. Develops provider engagement and activation strategies, performance frameworks, and scalable roadmaps while partnering with Markets, Clinical, Analytics, IT, Operations, and external provider organizations. The role requires expertise in Medicare Advantage, Stars, HEDIS, provider performance, value-based care, healthcare analytics, and enterprise initiative leadership.

Manages complex projects and programs from initiation through completion, primarily supporting Medicaid state implementations and insurance initiatives. Responsibilities include defining requirements, schedules, budgets, forecasts, milestones, and deliverables; coordinating cross-functional teams and vendors; managing resources, risks, issues, and stakeholder communication; monitoring performance; and driving strategic alignment and continuous improvement. The role requires independent judgment, leadership, and effective execution across Agile, Waterfall, or hybrid environments.

Leads decision intelligence and agentic AI engineering across Humana’s NBA platform. Models business decisions, designs decision services and optimization strategies, and builds production AI workflows using LLMs, retrieval, tool calling, and orchestration frameworks. Oversees microservices, databases, policy engines, testing, observability, governance, and compliance. Partners with data science and business teams to operationalize reinforcement learning and improve member engagement. Leads and mentors a small engineering team while remaining hands-on.

Leads sales support strategy and operations for a call center by analyzing performance, forecasting capacity, managing proficiency-based routing, automating reporting, and enabling technology improvements. Develops growth initiatives, business cases, dashboards, and executive recommendations while coordinating cross-functional projects across operations, technology, workforce management, marketing, finance, compliance, and training. Supports seasonal readiness, process improvement, leadership decision-making, and business continuity.

Develop and operate reinforcement learning systems powering Humana’s Next Best Action platform. Responsibilities include RL algorithm development, reward and constraint design, simulation and backtesting, distributed Databricks and Ray RLlib training, PySpark feature engineering, MLflow model governance, production deployment, safety evaluation, and integration with rules engines and feedback pipelines. The role also requires explainability, auditability, and collaboration with healthcare, data, platform, and compliance teams.

Reviews high-volume expedited Medicaid and dual appeals cases, evaluates clinical documentation, manages cases through resolution, conducts investigations, meets strict turnaround times, and contacts members or providers. The role requires queue management, accurate documentation review, adaptability to changing workflows, performance against production metrics, and communication across multiple workstreams. It is remote after training, with a Tuesday-through-Saturday schedule, alternating holidays, and occasional office travel.

Leads the strategy, operations, analytics, enablement, reporting, and continuous improvement of sales support functions. Partners with sales, marketing, product, operations, compliance, legal, and technology teams to improve sales effectiveness and customer outcomes. Oversees tools, workflows, dashboards, forecasting, data quality, training, change management, and cross-functional initiatives while building and developing a high-performing team.

Review utilization management activities and documentation to ensure policy and regulatory compliance. Collect and analyze outcome and operational metrics, process QIO fast-track appeals and expedited authorizations, make independent determinations, and follow regulatory turnaround times. Work a four-day, 10-hour shift schedule (Wed–Sun or Thu–Sun) in an EST-operating, remote role with strict home-office and internet requirements.

Supervises referral and authorization processing, coordinates team workloads, prioritizes caseloads, resolves operational issues, and implements contingency plans to meet performance standards. Provides training, coaching, and performance management for non-clinical associates while supporting their career development. Requires prior TRICARE experience, referral and authorization management expertise, supervisory experience, U.S. citizenship, and interim approval for a government security clearance.

Leads enterprise security architecture by assessing threats, performing application security assessments and threat modeling, reviewing designs, and integrating controls into SDLC and DevSecOps environments. Advises business and engineering stakeholders on secure solutions, remediates vulnerabilities, protects APIs, web applications, and cloud workloads, and improves security processes through automation and standardization.

Manages TRICARE provider relationships, network adequacy, access to care, stakeholder outreach, and resolution of beneficiary, provider, and government inquiries. Educates healthcare providers on TRICARE policies and regulations, supports value-based care initiatives and payment demonstrations, maintains compliance documentation, and ensures consistent service delivery across the assigned East Region territory. The role requires independent decision-making, strong communication, customer relationship management, and collaboration with healthcare and government stakeholders.

Leads Humana’s Pharmacy Stars clinical programs focused on Medicare medication adherence, patient safety measures, and appropriate medication use. Autonomously develops, implements, and manages clinical strategies; analyzes complex data; makes recommendations; facilitates cross-functional collaboration; and manages multiple projects with minimal supervision. The role requires an active pharmacy license, substantial clinical or managed-care experience, strong communication, strategic planning, and the ability to make complex decisions.

Leads enterprise-scale, cross-functional programs and projects from feasibility through closeout, ensuring delivery on time, within budget, and aligned with business outcomes. Develops charters, plans, budgets, risk mitigations, stakeholder communications, and change-management activities. Facilitates meetings, oversees execution, manages quality and procurement, reports progress to executives, and supports organizational change. The role also applies project standards, ADKAR practices, and process-mapping tools in a remote shared-services environment.

Leads complex analytics initiatives and partners with business leaders to define problems, analyze pharmacy, sales, and operational data, and develop actionable recommendations. Manages engagements across the full analytics lifecycle, from discovery through solution delivery and implementation support. Designs metrics, dashboards, frameworks, and decision-support tools while communicating insights to executive, operational, and technical audiences. The role emphasizes consultative analytics and business problem solving rather than software development or data infrastructure engineering.

Leads enterprise procurement strategy for contingent workforce, outsourcing, offshoring, consulting, and clinical services. Advises senior business leaders on operating models, sourcing decisions, business cases, commercial structures, negotiations, transitions, supplier performance, and value realization. Builds high-performing procurement teams and oversees complex services portfolios across Insurance and Corporate Services, balancing cost, quality, compliance, workforce agility, resiliency, and transformation outcomes.

Reviews clinical documentation to assess grievances, appeals, and additional requests; issues final determinations in collaboration with clinical and internal teams. Assigns cases for independent second-level review, tracks case distribution and volumes, maintains quality and productivity standards, and manages priorities in a fast-paced environment. The role is remote, requires occasional travel for training or meetings, and includes an 18-month department commitment.

Supports healthcare economics and value-based care initiatives through claims and revenue analysis, forecasting, financial reconciliation, performance measurement, and strategic insights. Develops scalable actuarial methodologies, reporting metrics, and analytical models; validates results and translates complex business requirements into end-to-end solutions. Partners with actuarial, finance, analytics, and business teams while working independently on complex and occasionally ambiguous assignments.

Manages Level 1 appeal cases by reviewing clinical documentation, validating determinations, coordinating with clinical and internal teams, and resolving member and provider issues. Ensures CMS compliance, confidentiality, accuracy, and timely case resolution while handling high-volume assignments in a production-driven environment. Requires flexibility for varied shifts, weekends, overtime, and occasional travel to Humana offices.

Leads actuarial risk and compliance activities for Medicare Advantage and prescription drug plan bid filings. Maintains and runs the CMS Out-of-Pocket Cost Model, interprets results, resolves compliance test failures, supports CMS audits, and develops filing controls and process improvements. The role assesses business risks, advises executives, reviews regulatory practices, and leads actuarial or support staff, including a direct report.