Policy Governance Professional

Become a part of our caring community
 

The Policy Governance Professional supports the Medicaid Utilization Management Policy Governance program. Reporting to the Policy Governance Lead, the primary responsibility of this role is to manage the end-to-end Medicaid UM Rates and Timeliness evaluation and reporting process across applicable markets, including physical health and behavioral health. Responsibilities include coordinating reporting schedules and data validation with accountable teams, evaluating performance trends, investigating potential contributing factors with operational and clinical stakeholders, developing clear written evaluations and recommendations, coordinating physician leadership review and committee approval, and tracking follow-up actions and supporting documentation. The role supports coordination of other UM-related QIE elements as responsibilities are established.

Job Responsibilities

o    Own and coordinate the end-to-end NCQA UM Rates and Timeliness Report process across applicable Medicaid markets and lines of business.

o    Manage reporting calendars, milestones, stakeholder responsibilities, data collection, validation, approvals, and final deliverables.

o    Partner with operational, analytical, clinical, quality, compliance, accreditation, and market teams to resolve data issues and report risks.

o    Analyze results to identify trends, outliers, performance concerns, and opportunities for improvement.

o    Coordinate, document, and monitor corrective or follow-up actions, escalating overdue or high-risk items as appropriate.

o    Prepare reporting summaries and materials for review by Utilization Management Committees, leadership, and other governance bodies.

o    Maintain complete, organized, and audit-ready documentation supporting reporting results, decisions, approvals, and committee oversight.

o    Support broader Policy Governance activities, including committee operations, policy lifecycle processes, regulatory alignment, process documentation, and continuous improvement.

o    The role also supports related policy governance, accreditation, compliance, and process-improvement activities.

Use your skills to make an impact
 

Required Qualifications

o    Bachelor’s degree

o    Experience in healthcare industry (operations, utilization management, quality, compliance, accreditation, reporting, governance, or a related area.)

o    Proficiency with Microsoft Excel, PowerPoint, Word, SharePoint, and related collaboration or tracking tools.

Preferred Qualifications

o    Experience supporting Medicaid managed care or another government-sponsored healthcare program.

o    Knowledge of NCQA accreditation standards and experience supporting accreditation survey preparation.

o    Experience supporting governance committees or other formal oversight bodies.

o    Experience interpreting regulatory, contractual, accreditation, or policy requirements.

o    Experience coordinating corrective actions, performance improvement activities, or audit responses.

o    Familiarity with data validation, reporting controls, and centralized national/state policy governance models.

Additional Information

Location: Remote US Nationwide

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Interview Format  

As part of our hiring process, we will be using an exciting interviewing technology provided by Hire Vue, a third-party vendor.  This technology provides our team of recruiters and hiring managers an enhanced method for decision-making. 

Work at Home Requirements: 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. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

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 demonstrated job related skills, knowledge, experience, education, certifications, etc.$65,000 - $88,600 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.Application Deadline: 10-26-2026

About us
 

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.

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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.