The Health Services Lead serves as the subject matter expert and operational leader supporting the design, implementation, and sustainability of Utilization Management (UM) clinical programs. This role ensures clinical integrity, regulatory alignment, and consistency across markets while advancing national UM strategy, standardization, and governance priorities.
The Health Services Lead serves as a key partner to Market teams, Strategy Advisors, enterprise shared service partners, operational leaders, and cross-functional teams, ensuring clinical requirements are translated into practical policies, standardized workflows, and scalable processes that support consistent execution.
Role Responsibilities
- Clinical workflow validation and recommendations
- UM input into program design and implementation plans
- Policy and procedure review with documented clinical and operational feedback
- UM clinical decision-making guidance and escalation support
- Documented clinical and/or operational scenarios, decisions, assumptions, and recommendations to reduce ambiguity
- Contributions to training materials, role-specific job aids, and reference resources
- Input into system configuration or technical build requirements for UM workflows
- Implementation readiness assessment, including identification of workflow gaps, risks, dependencies, and training needs
- Policy development and approval to include ESP information requests
- Workflow adoption support and post-implementation feedback gathering
- Post-implementation evaluation of program effectiveness, including clinical workflow adoption and readiness gaps
- Process improvement and standardization recommendations
- Risk, issue, and dependency documentation for clinical, regulatory, operational, or market-specific concerns
Use your skills to make an impact
Required Qualifications
- Active Licensed Registered Nurse, RN in your state of residence without disciplinary action OR Licensed Practical Nurse (LPN), Social worker (LCW, LCSW), counselors (LPC, LCPC, LMFT)
- 3+ years managed care in health plan, Medicare/Medicaid experience
- 3+ years utilization management experience
- Experience with policy, process, workflow, proofing and formatting
- Reviews data to identify trends and opportunities for process improvement.
- Proficient in Excel and Word
Additional Information
Workstyle: Remote work at Home
Schedule: Monday through Friday 8:00 AM -5:00 PM Eastern time and may fluctuate during high demand business needs.
Travel: Must be available to travel to various Humana locations, which may include out of state for new business once a month and occasionally for meetings and/or trainings.
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. 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.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay Range
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.
$94,900 - $130,500 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
Application Deadline: 08-06-2026
