Policy Governance Professional

The Policy Governance Professional supports the Medicaid Utilization Management Policy Governance program. Reporting to the Policy Governance Lead, the primary responsibility of this role is to manage the end-to-end Medicaid UM Rates and Timeliness evaluation and reporting process across applicable markets, including physical health and behavioral health. Responsibilities include coordinating reporting schedules and data validation with accountable teams, evaluating performance trends, investigating potential contributing factors with operational and clinical stakeholders, developing clear written evaluations and recommendations, coordinating physician leadership review and committee approval, and tracking follow-up actions and supporting documentation.

The role supports coordination of other UM-related QIE elements as responsibilities are established.

• Own and coordinate the end-to-end NCQA UM Rates and Timeliness Report process across applicable Medicaid markets and lines of business.
• Manage reporting calendars, milestones, stakeholder responsibilities, data collection, validation, approvals, and final deliverables.
• Partner with operational, analytical, clinical, quality, compliance, accreditation, and market teams to resolve data issues and report risks.
• Analyze results to identify trends, outliers, performance concerns, and opportunities for improvement.
• Coordinate, document, and monitor corrective or follow-up actions, escalating overdue or high-risk items as appropriate.
• Prepare reporting summaries and materials for review by Utilization Management Committees, leadership, and other governance bodies.
• Maintain complete, organized, and audit-ready documentation supporting reporting results, decisions, approvals, and committee oversight.
• Support broader Policy Governance activities, including committee operations, policy lifecycle processes, regulatory alignment, process documentation, and continuous improvement.
• The role also supports related policy governance, accreditation, compliance, and process-improvement activities.

• Bachelor’s degree
• Experience in healthcare industry (operations, utilization management, quality, compliance, accreditation, reporting, governance, or a related area.)
• Proficiency with Microsoft Excel, PowerPoint, Word, SharePoint, and related collaboration or tracking tools.

• Experience supporting Medicaid managed care or another government-sponsored healthcare program.
• Knowledge of NCQA accreditation standards and experience supporting accreditation survey preparation.
• Experience supporting governance committees or other formal oversight bodies.
• Experience interpreting regulatory, contractual, accreditation, or policy requirements.
• Experience coordinating corrective actions, performance improvement activities, or audit responses.
• Familiarity with data validation, reporting controls, and centralized national/state policy governance models.

Location:

Remote US Nationwide

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

As part of our hiring process, we will be using an exciting interviewing technology provided by Hire Vue, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

Work at Home Requirements:
To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is…