Clinical Policy Operations Professional

Position: Clinical Policy Operations Professional 2
** Become a part of our caring community*
* The Clinical Policy Operations Professional 2 provides operational support to clinical pharmacists for the implementation, maintenance, submission, and ongoing management of clinical policies, drug lists, and benefit requirements. This role focuses on accurately translating approved clinical strategies into operational systems and tools, requiring strong attention to detail, independent problem solving, and consistent execution within established processes.

The Clinical Policy Operations Professional 2 ensures accuracy and compliance for utilization management (UM) criteria within the Clinical Policy System, operational guidance documentation, and the submission and maintenance of policies provided to external accreditation and review bodies. They collaborate with healthcare professionals, pharmacists, and business stakeholders to operationalize clinical policy strategies and perform quality analysis and reporting to ensure effective operational execution.

This role creates process and training documentation as appropriate. They understand department, and organizational strategy and operating objectives, including their linkages to related areas. They make decisions regarding their own work methods, occasionally in ambiguous situations, and require minimal direction while seeking guidance when needed. They follow established guidelines and procedures. Success in this role requires strong attention to detail, comfort working within established processes, sound judgement, and the ability to manage recurring operational responsibilities with a high degree of accuracy.

+ Collaborates with Clinical Subject Matter Experts to translate complex clinical recommendations into standardized policy criteria and operational requirements within formulary and clinical policy systems.

+ Interprets Medicare and state-specific Medicaid regulations, benefit requirements, and operational guidance to support the accurate implementation and maintenance of state-specific clinical policies and utilization management strategies

+ Partners with clinical, operational, and business stakeholders to ensure clinical policy intent is accurately reflected in formulary structures, utilization management criteria, and system configuration. Performs detailed reviews to ensure policy configurations and operational guidance align with approved clinical and business requirements

+ Supports cross-functional efforts related to policy implementation, operational processes, and workflow management across clinical and business teams

+ Participates in cross-functional initiatives to streamline policy implementation, workflow management, and operational review processes across clinical and operational teams.

** Use your skills to make an impact*
* ** Required Qualifications*
* + Bachelor's degree

+ Less than 5 years of technical experience

+ Strong collaboration and relationship-building skills

+ Excellent written and verbal communication skills

+ Excellent planning and organizational skills

+ Demonstrated ability to manage complex operational processes requiring a high degree of accuracy, attention to detail, and independent problem solving

+ Working knowledge of all Microsoft Office applications, including Word, Excel and Outlook

+ Ability to work on multiple, competing projects

+ Ability to successfully handle change in a fast-paced environment

+ Must be passionate about contributing to an organization focused on continuously improving consumer experiences

+ Proven ability to collaborate across departments and lines of business to support alignment and operational execution

** Preferred Qualifications*
* +

Experience with data analysis, reporting, and process measurement tools (e.g., Excel, Access, Power BI)

+ Previous experience in pharmacy benefits management or healthcare operations

+ Experience supporting Medicare and/or managed Medicaid programs

+ Experience working in cross-functional operational, policy, or implementation environments

** Additional Information:*
* As part of our hiring process for this opportunity, we will be using an interviewing technology called Hire Vue to enhance our hiring and decision-making ability. Hire Vue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

** 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 required; wireless, wired cable or DSL connection is suggested.

Satellite, cellular and microwave connection can be used only if approved by leadership.

Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

Humana will provide Home or Hybrid…