SVP, Clinical Operations Leader

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The Senior Vice President (SVP), Clinical Operations Leader is responsible for the strategic direction, oversight, and operational excellence of clinical care management programs serving Medicare Advantage and Medicaid members. This executive role leads multi‑disciplinary teams—including telephonic care management, clinical advocacy (behavioral health, social work, dietitians), inpatient and outpatient utilization management, utilization management and care management risk/compliance/quality oversight and partnering with clinical enablement (technology and tools)—to deliver high‑quality, compliant, and member‑centric care.

The SVP partners with key stakeholders across the organization to drive performance, innovation, regulatory compliance, and continuous improvement.

This position reports to Chief Operating Officer of Insurance and has 5 direct reports and a team of roughly 8,000 associates.

• Provide executive leadership for telephonic care management programs, ensuring exceptional member engagement and outcomes for Medicare Advantage populations. Delivering on STAR and HEDIS measures.

• Lead the Clinical Advocacy team (behavioral health, social workers, dietitians) to optimize support for member health and well‑being, addressing complex care needs and social determinants of health and close gaps in care through interdisciplinary team.

• Oversee clinical inpatient and outpatient utilization management functions by registered nurses and medical directors, ensuring appropriate, cost‑effective, and compliant care for Medicare Advantage and Medicaid members. Continue to engage off‑shipping opportunities and work closely with clinical vendors.

• Lead risk, compliance, and quality teams within UM and CM to maintain adherence to federal and state regulations, accreditation standards, and organizational policies; ensure ongoing performance improvement and mitigation of risk.

• Guide the Clinical Enablement team in the development and deployment of technology solutions and tools that enhance workflow efficiency and clinical effectiveness across all care management and utilization management teams.

• Establish and monitor performance metrics, KPIs, and reporting systems to assess program effectiveness and inform strategic decision‑making.

• Collaborate with cross‑functional leaders (Medical Directors, IT, Product, Quality, Regulatory Affairs, Finance) to ensure alignment of clinical operations with enterprise goals.

• Foster a culture of continuous improvement, innovation, and professional development within all clinical operations teams.

• Represent clinical operations at internal and external forums, including executive meetings, industry conferences, and regulatory engagements.

• Bachelor’s degree

• Minimum 10 years of progressive leadership experience

• Demonstrated success in leading large, multi‑disciplinary teams and managing complex organizational change.

• Experience with development and implementation of technology solutions and tools.

• Strong analytical, strategic planning, and communication skills.

• Ability to build collaborative relationships and influence across all levels of the organization.

• Master’s degree

• Leadership experience in clinical operations, care management, and utilization management within managed care, health insurance, or integrated health systems.

• Deep knowledge of Medicare Advantage and Medicaid regulations, risk adjustment, compliance, and quality standards (e.g., CMS, NCQA, URAC).

• Position is remote nationwide; however, preference will be given to those residing or willing to relocate to Louisville, KY, Chicago IL, Nashville, TN, Washington D.C., Fort Lauderdale or Tampa, FL.

• This is a senior executive role with high visibility and impact. The position may require travel and participation in external meetings as a representative of the organization.

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

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