Clinical Business Lead

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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

• 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.

• 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.

• 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).

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 required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

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

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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 -…