Clinical Business Lead

About the Role: Clinical Business Lead at Humana

The Clinical Business Lead plays a pivotal role in leading teams of nurses and behavioral health professionals focused on care management. This position addresses problems of diverse scope and complexity, ranging from moderate to substantial, contributing significantly to Humana's mission of putting health first.

Primary Responsibilities

Data Analytics to Support Clinical Strategy, Performance Reporting, and Monitoring:

• Analyze chronic condition performance to provide regional clinical leadership with insights for provider groups, driving awareness, education, and action plans.
• Evaluate the effectiveness of clinical program initiatives through analysis of their downstream impact on facility and provider performance within value-based programs.
• Identify opportunities for new clinical program initiatives by assessing cost and utilization drivers, with a dedicated focus on chronic conditions.
• Support facility case review discussions with comprehensive pre-meeting analysis of submitted case reviews as required.
• Prepare data and evaluate performance to support Regional Vice President (RVP) and Health Services Director (HSD) in governance and delegation oversight committee interactions, coordinating with corporate delegation compliance and auditing teams.

Cross-Functional Collaboration With Key Stakeholders:

• Collaborate with cross-functional teams and internal stakeholders to ensure clinical strategies are aligned with regional executive leadership.
• Serve as a clinical liaison to the provider engagement team, ensuring consistent execution of initiatives.
• Collaborate with the delegation team to proactively identify and resolve performance issues or access concerns.

Compliance And Quality Improvement:

• Support regional leadership in maintaining rigorous compliance with clinical best practices and regulatory standards.
• Participate in continuous quality improvement initiatives, including root cause analysis and implementing best practices to close care gaps effectively.

Vendor/Pilot Program Evaluation And Monitoring:

• Coordinate the implementation of clinical vendor programs across the region, ensuring operational readiness, thorough provider education, and ongoing support for seamless integration.
• Assist in the evaluation of clinical program pilots and vendor-supported initiatives through in-depth analysis and monitoring of key performance indicators.
• Track vendor performance metrics and collaborate with the finance team to prepare comprehensive performance reports, supporting data-driven decision making and demonstrating ROI.
• Review delegation team audits and, if necessary, supplement them with regular reviews to ensure vendor programs comply with regulatory standards and internal policies.
• Provide valuable insights to inform program scalability and effectiveness.

Required Qualifications

Use your skills to make an impact:

• Bachelor's degree in a health-related field (e.g., Nursing, Public Health, Epidemiology, Healthcare Administration).
• Minimum of 5 years of clinical experience.
• Minimum 3 years of experience in data analytics, clinical operations, care management, quality improvement, or vendor oversight.
• Proficient in analyzing and presenting data using visualization tools (e.g., Excel, Tableau, Power BI) and interpreting it for various audiences.
• Strong understanding of value-based care, population health, and clinical quality metrics.
• Experience managing or supporting third-party vendor relationships in a healthcare setting.
• Excellent organizational, communication, and problem-solving skills.
• Proven ability to provide high-quality, responsive service to internal and external stakeholders.
• Demonstrated ability to lead through influence and collaborate across teams.
• Thrive in a remote work environment with independent work skills.
• Travel expected 5-15%.

Preferred Qualifications

• Advanced Degree (such as MSN, MBA, MHA, MPH).
• Experience in managed care, health plan operations, or Medicare Advantage programs (including various SNP products) or Managed Medicaid.
• Familiarity with remote monitoring, digital health tools, or clinical innovation platforms.
• Project management experience or certification (e.g., PMP, Lean Six Sigma).

Work-At-Home Requirements

To ensure Home or Hybrid Home/Office associates' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Associates 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 Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Key skills/competency

• Clinical Care Management
• Data Analytics & Visualization
• Value-Based Care
• Population Health
• Quality Improvement
• Vendor Management
• Cross-functional Collaboration
• Regulatory Compliance
• Healthcare Operations
• Project Management