VP, Clinical Policy and Risk Management

Humana

. Oversee a department comprising 7 direct reports and 250 associates leading CM/UM Risk Management, UM and CM audit teams, and policy governance .

Posted 9/18/2026full-timeRemote • United StatesLeadWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in CM/UM Risk Management, regulatory compliance, and operational controls, with a strong focus on risk mitigation and continuous improvement. Proven ability to lead teams, manage complex stakeholder relationships, and ensure alignment with regulatory requirements.

Highest-signal resume keywords

CM/UM Risk ManagementRegulatory ComplianceOperational ControlsLeadership ExperienceProject Management

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical LicenseRisk Mitigation StrategiesOperational Metrics MonitoringCMS Federal RegulationsMedicaid State RegulationsInternal ControlsClinical Risk ManagementProcess ImprovementAudit FacilitationBusiness Continuity Oversight

Soft Skills

CollaborationInfluencing OutcomesCommunication SkillsIntegrityBusiness Ethics

Certifications & Qualifications

Active Clinical License

Industry Keywords

CM/UM ProcessesFraud Risk IdentificationLegislative RequirementsQuality ImprovementStakeholder Engagement

About the role

Key responsibilities & impact

Oversee a department comprising 7 direct reports and 250 associates leading CM/UM Risk Management, UM and CM audit teams, and policy governance
Identify, assess, and report operational and clinical risks within CM/UM processes to appropriate governance structures
Monitor CM/UM compliance and operational metrics, escalating and resolving issues impacting member care or regulatory compliance
Track, interpret, and implement CMS Federal and Medicaid State regulations affecting CM/UM
Support regulatory audits focused on CM/UM compliance and facilitate remediation
Lead risk mitigation efforts for care management and utilization management, including maturity assessments and oversight of issues and opportunities
Oversee CM/UM business continuity and work across leadership to resolve IOPs
Foster quality and continuous improvement within CM/UM control processes
Address legislative and regulatory issues affecting CM/UM operations, including fraud risk identification and mitigation
Partner with Legal, Compliance, Regulatory Affairs, and business leaders on emerging regulatory and legal risks, legislative requirements, audit and litigation readiness, and alignment with applicable laws
Report directly to the Senior Vice President – Clinical Operations

Requirements

What you’ll need

Bachelor’s degree required; MBA preferred
Active, unrestricted clinical license in the applicable discipline (e.g., RN, LCSW, LPC, LMFT, PharmD, MD/DO, or other relevant clinical credential)
Ability to apply clinical expertise, professional judgment, and regulatory knowledge to support business, operational, and member outcomes
10+ years of experience in CM/UM risk management, regulatory compliance, process improvement, or related fields
6+ years in leadership roles
Advanced knowledge of CM/UM operational controls, risk mitigation strategies, and regulatory requirements for Medicare and Medicaid
Expertise in internal controls, clinical and operational risk management, and IT technical controls within CM/UM environments
Exceptional project management skills, integrity, and business ethics
Ability to collaborate with stakeholders across the enterprise and influence outcomes in complex, matrixed environments
Excellent communication skills and executive presence

Benefits

Comp & perks

Occasional travel to Humana's offices for training or meetings may be required
Self-provided internet service with minimum 25 Mbps download and 10 Mbps upload
Dedicated workspace to protect member PHI / HIPAA information