[Hiring] Chief Medical Officer, Utilization Management @Humana

Role Description

The Chief Medical Officer, Utilization Management (UM) will serve as the clinical strategist, operator, and visionary for Humana’s Utilization Management organization. This executive role is responsible for integrating and overseeing all Outpatient and Inpatient based MDs and RNs and non-clinical support for UM functions in Medicaid and Medicare, with a focus on streamlining processes, ensuring consistent clinical practices, driving trend savings, improving Star Ratings, and enhancing operational efficiency. The CMO, UM will ensure alignment with Humana’s strategic objectives and enterprise operating model.

Key Responsibilities:

• Set clinical strategy and lead the Utilization Management organization.
• Oversee the integration of medical doctors and registered nurses in UM across Medicaid and Medicare.
• Provide leadership in risk management, grievance and appeals, clinical contracting, vendor management, and UM dental review.
• Ensure the clinician’s perspective is central to organizational decision-making.
• Leverage analytics to inform strategy and performance improvement.
• Sponsor the development of clinical talent and leadership pipeline.

Organizational Scope:

The Chief Medical Officer, UM leads a significant functional organization, with direct accountability for human capital and organizational performance.

• Direct reports include:
• VP, Physician Leadership
• Clinical contracting, physician review, quality improvement, legal MDs
• Director, Physician Leadership
• MD vendors, grievance and appeals
• AVP, UM Nursing
• UM RNs (transplant, behavioral health, appeals, etc.)
• Lead Dental Director
• Dental MD/RN review, bid season benefit review
• Director, Strategy Advancement
• Market liaison, provider/facility relationships
• AVP, UM Administration
• UM intake, vendor management, administrative support

Role Impact:

• Drive the formation, execution, and sustainability of Humana’s Utilization Management strategy.
• Challenge the healthcare status quo to improve quality, Star Ratings, and health outcomes.
• Integrate evidence-based approaches for UM reviewers.
• Support Humana’s commitment to whole-person health and consistent, high-quality outcomes.

Qualifications

• MD/DO
• Current Board Certification
• Minimum 10 years of combined leadership and/or UM experience.
• Passion for improving Star Ratings, review consistency, and health outcomes.
• Deep knowledge of medical, clinical, and behavioral science underpinning UM.
• Strong interpersonal, leadership, and business acumen.
• Proven ability to drive cross-functional results and champion clinical perspectives.

Requirements

• To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service must meet the following criteria:
• Minimum download speed of 25 Mbps and 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.
• While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

• 40

Application Deadline

• 10-29-2026