Humana

Auditor

• Perform clinical audit and validation processes to ensure medical record documentation and diagnosis coding are complete, compliant, and accurate
• Validate and interpret medical documentation to capture all relevant coding
• Identify members with high-risk CMS Hierarchical Condition Categories (HCC)
• Refer cases for annual follow-up care by disease management, case management, and primary care providers as appropriate
• Identify root causes of audit findings and submit change-management recommendations
• Review provider codes and billing using clinical and coding expertise
• Interpret department, segment, and organizational strategy and operating objectives and their linkages to related areas
• Make decisions regarding work methods in occasionally ambiguous situations with minimal direction
• Follow established guidelines and procedures
• Work remotely during typical Monday-Friday business hours, 8 hours per day
• Occasionally travel to Humana offices for training or meetings

Nurse Auditor

Manager

• Provide comprehensive social service care management for frail elders and adults with intellectual, developmental, or physical disabilities in Wisconsin's Family Care program
• Learn what is important to members and support them in achieving it
• Partner with a Health and Wellness Coordinator (RN) and collaborate on member needs and care plans
• Perform face-to-face social-related assessments upon enrollment and at least every six months thereafter in the member's setting
• Coordinate, perform, and track quarterly face-to-face visits and monthly phone contacts
• Participate in development, ongoing review, and coordination of members' plans of care
• Lead social, community integration, employment, housing, and non-health-related issues
• Educate members on and promote prevention and wellness and mitigate assessed risks
• Document activities and complete required paperwork
• Travel throughout Jefferson County and provide services at business partner facilities or members' homes

Case Manager

Nurse

• Review prior authorization requests for appropriate care and setting
• Follow guidelines and policies when approving services or forwarding requests to the appropriate stakeholder
• Complete medical necessity and level-of-care reviews using clinical judgment
• Refer cases to team members for review based on findings
• Educate providers on utilization and medical management processes
• Enter and maintain relevant clinical information in medical management systems
• Interpret department, segment, and organizational strategy and operating objectives
• Make independent decisions regarding work methods in ambiguous situations
• Follow established guidelines and procedures

Pre-Authorization Nurse

• Support coordination, documentation, and communication of medical services or benefit administration determinations
• Interpret criteria, policies, and procedures using behavioral health skills and clinical knowledge
• Provide appropriate treatment, care, or services for members
• Coordinate and communicate with providers, members, and other parties to facilitate optimal care and treatment
• Make independent determinations and decisions regarding work methods and courses of action
• Follow established guidelines and procedures
• Work from a dedicated home workspace and maintain required internet connectivity
• Travel occasionally to Humana offices for training or meetings

Behavioral Health Nurse

• Lead teams of nurses and behavioral health professionals responsible for care management
• Oversee assessment and evaluation of members’ behavioral health needs and requirements
• Guide members and families toward appropriate care and wellbeing resources
• Make decisions on resources, approaches, and tactical operations for departmental projects and initiatives
• Work cross-departmentally and conduct briefings and area meetings
• Maintain frequent contact with other department managers
• Identify and resolve barriers hindering effective care
• Apply department, segment, and organizational strategy and operating objectives
• Determine work methods and manage assignments with minimal direction
• Report to the Regional CM Associate Director
• Contribute to continuously improving consumer experiences

Manager, Care Management – Behavioral Health

Architect

• Design and develop IT application architecture solutions aligned with enterprise architecture direction and standards
• Perform technical planning, architecture development and modification of specifications
• Develop specifications for new products/services, applications and service offerings
• Assess compatibility and integration of proposed standard products/services
• Advise executives on significant functional strategies
• Lead architecture design, governance and strategic direction of the Specialty Integration Hub
• Define, establish and enforce integration architecture standards, design principles and best practices
• Partner with engineering, product and business stakeholders to translate business objectives into technology solutions and delivery roadmaps
• Drive enterprise API, data integration and cloud architecture strategies
• Provide architectural leadership through solution lifecycles, including design reviews, technology evaluations, risk assessments and governance oversight
• Mentor and guide technical teams
• Align with other architects on key deliverables and timelines
• Own end-to-end application architecture for Specialty across systems of experience, operations and insight
• Occasional travel to Humana offices for training or meetings may be required

Lead Application Architect

Full-stack Engineer

• Develop and execute multi-year category strategies and sourcing pipelines
• Lead end-to-end sourcing initiatives, including requirements development, market assessment, competitive events, supplier evaluation, negotiation, contracting, and implementation support
• Negotiate complex software, SaaS, cloud, data, and technology-enabled services agreements
• Advise senior business and technology leaders on sourcing strategies, market dynamics, supplier options, commercial risk, and trade-offs
• Partner with Legal, Finance, Information Security, Privacy, Risk, Compliance, Enterprise Architecture, Procurement Operations, and other stakeholders
• Evaluate and manage strategic suppliers across the contract lifecycle
• Deliver value through cost optimization, demand management, supplier consolidation, contractual protections, process improvement, and supplier-enabled innovation
• Develop financial analyses, business cases, negotiation strategies, savings forecasts, and executive-ready recommendations
• Monitor healthcare technology and supplier-market trends for emerging risks and opportunities
• Promote preferred suppliers, procurement policies, sourcing processes, and contract standards
• Coach peers and advance consistent category-management and sourcing practices

IT Procurement Lead – Software

• Review prior authorization requests for appropriate care and setting
• Follow guidelines and policies to approve services or forward requests to appropriate stakeholders
• Complete medical necessity and level-of-care reviews using clinical judgment
• Refer cases to internal stakeholders for review based on findings
• Educate providers on utilization and medical management processes
• Enter and maintain pertinent clinical information in medical management systems
• Interpret varied assignments and independently determine appropriate courses of action
• Work according to department, segment, and organizational strategy and operating objectives
• Make decisions regarding work methods with minimal direction
• Follow established guidelines and procedures

• Conduct comprehensive face-to-face assessments of newly admitted members at assigned acute care facilities
• Evaluate members’ physical, psychosocial, and health needs and refer them to Humana programs as appropriate
• Support and educate members and families on discharge planning from admission through post-discharge
• Facilitate follow-up visits with primary care providers
• Identify gaps in care, safety concerns, and barriers to discharge
• Develop and implement strategies to address care and discharge barriers
• Collaborate with attending providers, facility case managers, and other healthcare professionals
• Provide education on diagnoses, medications, and preventive measures
• Complete required documentation accurately and promptly
• Maintain infection control, safety, and patient privacy standards
• Work onsite at Camden Clark Memorial with limited remote documentation hours

Onsite Care Coordination Nurse

Director

• Drive technical support teams to recover services during service disruptions or outages affecting key technology platforms and applications
• Lead enterprise L1 support functions, including Service Desk Operations, Service Escalation Management, and affiliate support teams
• Provide leadership for a hybrid workforce of internal associates and managed service partners
• Develop and execute strategies to improve support effectiveness, associate experience, service delivery, and costs
• Drive AI-enabled support, automation, self-service adoption, knowledge management, Digital Workplace modernization, and workforce optimization
• Identify and execute shift-left opportunities to reduce reliance on higher-cost support tiers
• Lead integration and consolidation of affiliate and subsidiary support organizations into Humana's enterprise support operating model
• Provide executive oversight of managed service providers, including vendor performance, service quality, contractual compliance, and business outcomes
• Lead vendor contract negotiations, renewals, commercial discussions, service expansions, and transition planning
• Partner with sourcing, procurement, and technology leaders to optimize vendor investments and identify efficiencies and cost savings
• Oversee service transitions, organizational changes, and support model transformations while minimizing operational disruption
• Establish operational governance, performance metrics, and continuous improvement programs
• Leverage analytics and operational insights to inform strategic decisions and prioritize improvements

Associate Director, IT Service Desk

Project Manager

• Manage all aspects of projects from start to finish, ensuring completion on time and within budget
• Support insurance-segment initiatives, primarily Medicaid state implementations
• Design, communicate, and implement strategic initiatives supporting enterprise objectives
• Oversee program and project execution, monitoring progress and performance
• Proactively resolve operational challenges to minimize delays and ensure successful outcomes
• Identify, acquire, and manage internal staff, materials, and external vendors required for project delivery
• Prepare project documentation, including requirements, schedules, budgets, and forecasts
• Collaborate with cross-functional teams and stakeholders across the organization
• Conduct regular status meetings and reports to ensure transparency, track milestones, and address risks or issues
• Set priorities, delegate tasks, manage risks, and coordinate project teams to meet targets and deliverables
• Shape department strategy and drive continuous improvement across programs and initiatives
• Work independently using significant judgment and discretion in determining approaches and resource allocation

Senior Project Manager

Outside Sales

• Build trust and educate individuals on Humana’s Medicare Advantage plans and Life, Dental, Vision, and Prescription coverage
• Create face-to-face connections through grassroots marketing, community events, and in-home visits
• Drive self-generated sales, meet performance goals, and expand Humana’s market presence
• Become a valued resource and build relationships in the local community
• Work collaboratively with a team of 8–12 Medicare Sales Agents under the guidance of a Senior Manager and Regional Director

Medicare Sales Field Agent

Vice President

• Establish and oversee the enterprise framework for model governance, AI risk management, responsible AI and AI governance
• Provide independent second-line oversight and challenge of models, advanced analytics, machine learning, generative AI and emerging AI technologies
• Own and continuously enhance the enterprise model governance framework across the model lifecycle
• Define model risk appetite, risk taxonomy, minimum control standards, governance requirements and escalation thresholds
• Provide effective challenge over model development, validation, implementation, monitoring and performance
• Oversee the enterprise model inventory, ownership, accountability, documentation and risk classification
• Establish model validation standards covering conceptual soundness, performance, stability, data quality, bias, explainability and ongoing monitoring
• Govern third-party and externally developed models
• Develop and oversee the Responsible AI framework and principles
• Establish governance standards for fairness, bias, transparency, explainability, accountability, privacy, human oversight, safety, security and appropriate AI use
• Establish AI use-case risk intake, assessment, approval, monitoring and ongoing oversight processes
• Develop standards for responsible use of generative AI, large language models, AI agents, automated decision-making and emerging technologies
• Identify and address unintended consequences, model drift, hallucination, discrimination, explainability limitations and other AI-specific risks
• Own the enterprise AI risk management framework and associated governance processes
• Oversee the enterprise AI inventory and lifecycle monitoring
• Develop proportionate AI risk assessments and approval requirements
• Monitor AI performance, effectiveness, risk indicators, incidents, exceptions and emerging threats
• Partner with cybersecurity, Privacy, Legal, Compliance, Data Governance and Technology Risk functions
• Govern external AI providers, foundation models, APIs, AI platforms and third-party AI solutions
• Establish policies, standards, procedures, controls and governance committees for model and AI risk
• Define first-line ownership and second-line oversight responsibilities
• Monitor model and AI risk appetite metrics, tolerance thresholds and key risk indicators
• Lead Model Risk and AI Risk Governance committees and report to executive management, Risk Committees and Board Committees
• Lead a hybrid team of internal associates and specialized external partners
• Promote responsible AI and sound model governance through training, awareness, stakeholder engagement and enterprise-wide education

Associate Vice President, Model & AI Governance

• Assess and evaluate members' needs and requirements to achieve or maintain optimal wellness
• Guide members and families toward appropriate care and wellbeing resources
• Facilitate interaction with care and community resources
• Manage members' physical, environmental, and psychosocial health issues using varied strategies and techniques
• Identify and resolve barriers to effective care
• Monitor patient care through assessments and evaluations
• Ensure patients progress toward desired outcomes
• Create member care plans as needed
• Apply department, segment, and organizational strategy and operating objectives
• Travel up to 50% to support collaboration, conduct face-to-face meetings, and engage with staff, providers, members, and families
• Report to the Manager, Care Management of Behavioral Health

Field Care Manager, Nurse – BSN

Business Intelligence Analyst

• Lead state implementation readiness efforts for Medicaid markets
• Support regulatory and contractual reporting
• Lead enrollment analytics and compliance monitoring
• Develop analytics modernization initiatives across Medicaid markets
• Solve complex business problems using internal and external data sources
• Provide actionable insights and strategic direction to business leaders
• Serve as the primary analytics lead for Medicaid Enrollment Operations initiatives
• Design and implement analytics solutions with business leaders, operational teams, compliance organizations, and technology partners
• Exercise independent judgment on issues affecting state compliance, enrollment operations, contractual reporting, membership reporting, reconciliation, and operational performance
• Use Databricks, Power BI, SQL, and cloud-based data environments to create reusable and scalable solutions
• Influence strategy and identify operational efficiency opportunities
• Establish reporting standards and drive modernization efforts
• Reduce implementation effort while improving compliance, operational visibility, and business outcomes

Nurse Auditor

Case Manager

Pre-Authorization Nurse

Behavioral Health Nurse

Manager, Care Management – Behavioral Health

Lead Application Architect

IT Procurement Lead – Software

Pre-Authorization Nurse

Onsite Care Coordination Nurse

Associate Director, IT Service Desk

Senior Project Manager

Medicare Sales Field Agent

Associate Vice President, Model & AI Governance

Field Care Manager, Nurse – BSN

Medicaid Business Intelligence Lead