Humana’s Operational Risk Management organization is seeking a Risk Management Lead to coordinate the monthly data collection process, specifically aligned with CMS requirements for CDAG (Coverage Determination Appeals and Grievances) Collection regarding Initial Determinations, Appeals and Grievances within the Medicare sector. This position is responsible for ensuring compliance with regulatory requirements and supporting both business and IT stakeholders throughout the process. In addition, will implement the 2027 Protocol version of the CDAG Universes.
Key Responsibilities:
Maintain process documentation for the monthly data collection process in collaboration with team members.
Write logic to be applied to the collected data, identifying and reporting any data issues.
Facilitate Data Universe Generation Guides (DUGGs) discussion with business and routinely verify accuracy of information provided.
Host routine meetings with business partners and stakeholders.
Provide IT partners with comprehensive test cases for any developed solutions.
Conduct User Acceptance Testing (UAT) on IT-delivered solutions to ensure requirements are met.
Collaborate with business teams to interpret regulatory requirements, document their fulfillment, and communicate findings to leadership.
Ensure transparency for all enterprise stakeholders regarding identified issues.
Promote operational excellence by proactively identifying issues, performing root cause analysis, and driving ongoing process improvements.
Evaluate and compare new protocols that CMS may provide.
Provide support for program audits and respond to regulatory inquiries.
Manage relationships with a subset of delegate contributors and provide data validation audits with those delegates.
Required Qualifications:
Bachelor’s degree.
At least 3 years of project management experience.
Demonstrated ability to collaborate with product, business, and technical stakeholders to deliver effective solutions.
Experience working with large datasets in an enterprise setting.
3+ years working in data analytics space.
Preferred Qualifications:
Knowledge of Medicare regulatory requirements.
Business Intelligence experience using tools, such as PowerBI.
Proven track record in leading technology-focused initiatives.
Previous participation in CMS Program Audits or other regulatory audits.
Background in regulatory audit processes.
PMP Certification.
This role is not eligible for work visa sponsorship.
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.
Satellite, cellular and microwave connection can be used only if approved by leadership.
Employees 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 employees 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.
As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana’s secure website.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.Scheduled Weekly Hours
40Pay 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.
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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.Application Deadline: 05-12-2026
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
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