Jobs at Humana

Leads complex analytics initiatives and partners with business leaders to define problems, analyze pharmacy, sales, and operational data, and develop actionable recommendations. Manages engagements across the full analytics lifecycle, from discovery through solution delivery and implementation support. Designs metrics, dashboards, frameworks, and decision-support tools while communicating insights to executive, operational, and technical audiences. The role emphasizes consultative analytics and business problem solving rather than software development or data infrastructure engineering.

Provides non-clinical utilization management support for skilled nursing facility services. Responsibilities include managing chart-review requests, building and pending authorizations, contacting providers and members to verify clinical information, requesting records, documenting communications, preparing correspondence and determination letters, and coordinating with healthcare teams. The role is fully remote and requires administrative experience, healthcare documentation proficiency, and familiarity with utilization review or prior authorization processes.

Leads enterprise security architecture by assessing threats, performing application security assessments and threat modeling, reviewing designs, and integrating controls into SDLC and DevSecOps environments. Advises business and engineering stakeholders on secure solutions, remediates vulnerabilities, protects APIs, web applications, and cloud workloads, and improves security processes through automation and standardization.

Manages TRICARE provider relationships, network adequacy, access to care, stakeholder outreach, and resolution of beneficiary, provider, and government inquiries. Educates healthcare providers on TRICARE policies and regulations, supports value-based care initiatives and payment demonstrations, maintains compliance documentation, and ensures consistent service delivery across the assigned East Region territory. The role requires independent decision-making, strong communication, customer relationship management, and collaboration with healthcare and government stakeholders.

Leads Humana’s Pharmacy Stars clinical programs focused on Medicare medication adherence, patient safety measures, and appropriate medication use. Autonomously develops, implements, and manages clinical strategies; analyzes complex data; makes recommendations; facilitates cross-functional collaboration; and manages multiple projects with minimal supervision. The role requires an active pharmacy license, substantial clinical or managed-care experience, strong communication, strategic planning, and the ability to make complex decisions.

Develop and operate reinforcement learning systems powering Humana’s Next Best Action platform. Responsibilities include RL algorithm development, reward and constraint design, simulation and backtesting, distributed Databricks and Ray RLlib training, PySpark feature engineering, MLflow model governance, production deployment, safety evaluation, and integration with rules engines and feedback pipelines. The role also requires explainability, auditability, and collaboration with healthcare, data, platform, and compliance teams.

Leads enterprise-scale, cross-functional programs and projects from feasibility through closeout, ensuring delivery on time, within budget, and aligned with business outcomes. Develops charters, plans, budgets, risk mitigations, stakeholder communications, and change-management activities. Facilitates meetings, oversees execution, manages quality and procurement, reports progress to executives, and supports organizational change. The role also applies project standards, ADKAR practices, and process-mapping tools in a remote shared-services environment.

Develops and maintains end-to-end BI dashboards, reporting, and analytics solutions. Partners with leaders to define KPIs, optimize SQL and BI models, ensure data accuracy and governance, and support regulatory reporting. Uses healthcare data to deliver actionable insights, improve processes, and guide strategic decisions. Advises senior leadership through clear, data-driven communication while working with complex datasets and cross-functional teams.

Leads decision intelligence and agentic AI engineering across Humana’s NBA platform. Models business decisions, designs decision services and optimization strategies, and builds production AI workflows using LLMs, retrieval, tool calling, and orchestration frameworks. Oversees microservices, databases, policy engines, testing, observability, governance, and compliance. Partners with data science and business teams to operationalize reinforcement learning and improve member engagement. Leads and mentors a small engineering team while remaining hands-on.

Leads enterprise procurement strategy for contingent workforce, outsourcing, offshoring, consulting, and clinical services. Advises senior business leaders on operating models, sourcing decisions, business cases, commercial structures, negotiations, transitions, supplier performance, and value realization. Builds high-performing procurement teams and oversees complex services portfolios across Insurance and Corporate Services, balancing cost, quality, compliance, workforce agility, resiliency, and transformation outcomes.

Supports healthcare economics and value-based care initiatives through claims and revenue analysis, forecasting, financial reconciliation, performance measurement, and strategic insights. Develops scalable actuarial methodologies, reporting metrics, and analytical models; validates results and translates complex business requirements into end-to-end solutions. Partners with actuarial, finance, analytics, and business teams while working independently on complex and occasionally ambiguous assignments.

Manages Level 1 appeal cases by reviewing clinical documentation, validating determinations, coordinating with clinical and internal teams, and resolving member and provider issues. Ensures CMS compliance, confidentiality, accuracy, and timely case resolution while handling high-volume assignments in a production-driven environment. Requires flexibility for varied shifts, weekends, overtime, and occasional travel to Humana offices.

Leads actuarial risk and compliance activities for Medicare Advantage and prescription drug plan bid filings. Maintains and runs the CMS Out-of-Pocket Cost Model, interprets results, resolves compliance test failures, supports CMS audits, and develops filing controls and process improvements. The role assesses business risks, advises executives, reviews regulatory practices, and leads actuarial or support staff, including a direct report.

Analyzes and forecasts Medicare financial data, maintaining provider revenue and expense projection models and supporting tools. Integrates value-based provider impacts into financial and bid forecasts, develops risk modeling guidance, ensures data integrity, and establishes controls around data flows. Collaborates with stakeholders to resolve data anomalies through troubleshooting and root cause analysis. The role is remote, with occasional travel for training or meetings.

Manages a sales support team and enables field sales execution through strategic initiatives, sales operations, performance reporting, process standardization, and cross-functional collaboration. Oversees territory alignment, resource allocation, dashboards, forecasts, and data-driven improvements. Recruits, coaches, and develops direct reports while partnering with sales, marketing, compliance, training, analytics, HR, and external vendors. The role is remote with occasional travel to Humana offices for training or meetings.

Senior clinical executive leading Utilization Management across Medicare and Medicaid. Sets UM clinical strategy, integrates physician and nursing review, oversees grievances/appeals, clinical contracting, vendor management, and dental review. Leverages analytics to improve Star Ratings, review consistency, and outcomes while developing clinical leadership and aligning UM with enterprise strategy.

Owns the Medicare Risk Adjustment platform and technical portfolio by translating business needs into technical requirements, prioritizing enhancements, assessing business value, and coordinating business, analytics, and IT delivery teams. The role manages competing priorities, supports technical budgeting, identifies opportunities, escalates insights affecting Stars outcomes, and drives initiatives that maximize platform value. This is a remote position with occasional travel for training or meetings.

Lead product strategy, backlog management, and platform development for Adobe Experience Platform web integrations across authenticated and unauthenticated channels. Translate business, regulatory, and customer needs into product requirements while partnering with engineering, architecture, marketing, CRM, legal, privacy, and compliance teams. Drive consent, preference, identity, personalization, and downstream activation capabilities; support enterprise adoption; monitor KPIs, data quality, integration health, and compliance risk; and optimize customer experiences across digital and omnichannel platforms.

Sets pricing assumptions and develops Medicare Part D bid pricing models. Analyzes claims, drug utilization, member behavior, market dynamics, drug launches, regulatory changes, and clinical developments to forecast pharmacy costs. Maintains pricing tools and utilization projections, researches cost trends, collaborates with pricing, clinical, pharmacy, formulary, and finance teams, and communicates recommendations to leadership.

Review utilization management activities and documentation to ensure policy and regulatory compliance. Collect and analyze outcome and operational metrics, process QIO fast-track appeals and expedited authorizations, make independent determinations, and follow regulatory turnaround times. Work a four-day, 10-hour shift schedule (Wed–Sun or Thu–Sun) in an EST-operating, remote role with strict home-office and internet requirements.