Enterprise Utilization Clinical Decision-Making Governance Lead at Humana

**Become a part of our caring community and help us put health first**Become a part of our caring community and help us put health first for our members, providers and ourselves.Desired Lead Associate to lead and manage the enterprise framework to facilitate and document consistent clinical decision making. This includes ensuring appropriate monitoring controls are in place as well as ensuring identified opportunities are addressed. They will work closely with established functions inside utilization management (Medical Director, clinician decision making teams, quality audits, prior authorization list and clinical policy) as well as enterprise support teams (process, risk, strategy, delegate oversight teams and regulatory compliance). As needed, they facilitation MD to MD discussions to support education and awareness of enterprise standards for application of UMC approved clinical criteria. Finally, this team works closely with Clinical Risk Management to support enterprise MD speaker readiness for external audits or other inquiries.• *Specific responsibilities**Oversight of enterprise controls based on the established pillars for consistent clinical decision-making: self-identification, quality oversight and monitoring, calibration on criteria, and continuous process improvement.+ Building our simple framework processes.+ Documentation of controls and expectation for clinical decision making.+ Interfacing with established controls provided by quality audit, clinical policy, process policy/documentation and reporting teams.+ Established thresholds for monitoring and identifying appropriate actions when controls indicate process gaps.+ Review appeal overturns and provider complaints about coverage policies to make necessary changes.+ Driving continuous process improvement including supporting UM strategic initiatives.+ Identify potential gaps between the intended application of coverage policies versus the actual application of clinical reviewers.+ Recommend enhancements to the coverage policy template to help ensure consistent and accurate interpretation and application of coverage policies.+ Support decision template development process to help ensure that templates aligned with coverage criteria and regulatory and accreditation requirements.• *Center of excellence and support for requirements and expectations for UM Delegates and internal partners.**+ Proactively identifies potential risks and impacts to UM delegates based on Humana Business Decisions+ Manages Humana-to delegate discussions for consistent clinical decision making+ Ensures business decisions.+ Support Delegation Compliance, delegate business relationship owners, strategy teams and National delegate oversight and support team on UM issues.+ Evaluates available data on delegate clinical decision-making and partners with clinical risk and regulatory compliance to evaluate specific action to mitigate detected risk.+ Supports PAL/clinical policy intake processes when there is malalignment with PAL codes and clinical policy changes.+ Manages appeal process for delegate requires for changes to PAL or clinical policy.• *Developing and overseeing the plan for MD speaker engagement in CMS program audits**+ Work closely with Clinical Risk Management for documentation of roles, RACI and expectations for MD audit engagement.+ Drive enterprise discussion to decide on MD leadership and coordination for MD participation in CMS audits.+ Gain segment leadership alignment for plan and expectations when prepping for CMS program audit.+ Managing the CMS Audit speaker organization and readiness preparation.+ Support Humana MD participants with onboarding and engagement in rehearsals.+ Develop framework for supporting delegate audit readiness, coordinate with Delegation Compliance.+ Support large clinical vendor delegates with onboarding and engagement in rehearsals and defense in the CMS program audit.• *Required Qualifications**+ Bachelor's Degree or 2 years + experience working with CMS Compliance Regulations+ 3 or more years' experience leading and/or coaching+ 5+ years of audit, compliance, risk, or process consulting experience+ Strategically oriented, resourceful, influential, critical thinker with strong problem-solving skills+ 2 + years of project leadership experience+ Knowledge of regulations governing the health care industry+ Persuasive, collaborative business acumen with the ability to influence others+ Executive presentation skills and ability to communicate with all levels+ Ability to identify actionable insights from large data sets and translate them into strategies and secure buy-in through excellent written and verbal communication• *Preferred Qualifications**+ Registered Nurse+ Experience in Medicare Utilization Management+ Project Management Professional (PMP) certification+ Six sigma certifications+ Experience in an audit or compliance role for a Health Plan or provider-based industry+ Knowledge and experience in health care/managed care regulatory environment• *Use your skills to make an impact**• *Work-At-Home Requirements**+ WAH requirements: Must have the ability to provide a high-speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.+ A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.+ Satellite and Wireless Internet service is NOT allowed for this role.+ A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information• *Interview Format**As part of our hiring process, we will be using an exciting interviewing technology provided by HireVue, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.• *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 dem