Jobs at Humana

Reviews utilization management activities and documentation to ensure policy and regulatory compliance, detect fraud/waste/abuse, and process QIO appeals and expedited authorizations. Collects and analyzes outcome and operational metrics, exercises independent judgment on complex cases, and works remotely on a four-day, 10-hour shift (Wed–Sat or Thu–Sun) within EST. Requires strong telephonic/virtual communication and home office internet/HP A protections.

Lead AI-driven reconciliation and automation to improve encounter data quality. Own model performance, identify root causes, partner with technical and business teams to enhance models, prioritize roadmap, and scale automation while communicating results to stakeholders.

Maintain and build data products, pipelines, and automation to support care management and clinical programs. Integrate multiple data sources into single sources of truth, perform root cause analysis, and serve as a subject-matter expert for partner teams to drive clinical, operational, and financial insights.

Design and optimize user-centered content for Humana's digital products. Own content for features and user journeys, simplify complex healthcare information, support information architecture and design systems, collaborate with cross-functional teams, and use research and analytics to iterate and improve accessibility, findability, and content performance.

Provide data-driven strategic direction for network and cost optimization in Home Health value-based care. Lead cross-functional projects, advise executives, analyze internal and external data, ensure regulatory compliance, and support expansion of value-based programs.

Embed as the primary analytics partner on a digital product team to define KPIs, own measurement plans, build PowerBI dashboards, analyze member product behavior and funnels, design and evaluate A/B tests, write SQL/Python for analyses, and translate findings into actionable recommendations for product leaders and senior stakeholders.

Lead product strategy and roadmap for Adobe Experience Platform to enable Next Best Action. Translate business and regulatory needs into product requirements, drive platform integrations, ensure data/consent governance, support cross-functional adoption, and measure KPIs to optimize personalization and activation across omnichannel touchpoints.

Lead post-acute network management analytics and develop an alternative payment model. Ensure data integrity by building processes and controls, troubleshoot and root-cause data issues, collaborate with partners, advise executives on strategy, and analyze variables to guide decision-making.

Perform actuarial analytics and forecasting to model financial and market trends, support value-based care contracting and implementation, ensure data integrity, develop metrics and forecasts, troubleshoot data issues, and advise leadership to inform strategic and operational decisions.

Lead Product Owner translates product strategy and CMS interoperability/regulatory requirements into actionable backlogs for Agile teams. Primary focus on ePA APIs and FHIR-based interoperability, driving backlog prioritization, user story development, acceptance criteria, stakeholder alignment, and delivery execution. Serves as primary liaison among product, compliance, architecture, and engineering to ensure scalable, compliant solutions.

Lead pharmacy compliance for Medicare Part B and D by developing policies, interpreting regulatory/contract requirements, auditing PBM and dispensing operations, supporting regulator audits, conducting risk assessments, monitoring performance, and advising business units. Collaborate cross-functionally, present to regulators, and support remediation and continuous improvement efforts.

Design, build, and deploy LLM-based applications and multi-step AI workflows (retrieval, orchestration, agents) using large-scale structured and unstructured data. Partner with engineering to productionize solutions, implement evaluation and safety measures, ensure compliance and data governance, and communicate results to technical and non-technical stakeholders.

Partner with channel leadership to own performance reporting, dashboards, and scorecards; analyze KPIs, identify risks and opportunities, deliver data-driven insights, support forecasting, target-setting, and compensation measurement, and drive continuous improvement and reporting automation across the assigned sales channel.

Design, train, and evaluate reinforcement-learning policies for Humana's Next Best Action platform. Build and instrument large-scale training pipelines, ensure operation within clinical constraints, collaborate with data and platform engineers, diagnose policy failure modes, and deploy reliable production decision systems.

Builds and manages ETL processes and data pipelines in Azure Databricks using PySpark. Integrates data from multiple sources, tunes Spark and SQL for performance, troubleshoots pipeline failures, automates manual processes, and supports reporting and analytics to inform business decisions.

Lead and manage AR/AP and patient billing operations for a multi-site primary and specialty care organization. Oversee denial management, claims follow-up, credit balance resolution, refunds, vendor partnerships, performance metrics, and process improvements while collaborating with clinical, compliance, contracting, and finance teams.

Manage utilization management nursing operations by applying clinical nursing knowledge to coordinate, document, and communicate care and benefit determinations. Interpret criteria, collaborate with providers and members, lead projects, supervise cross-departmental initiatives, and ensure appropriate treatment and resource allocation while supporting remote work and occasional travel.

Lead product strategy for member engagement, retention, loyalty, and lifecycle across digital and assisted channels. Own retention, NPS, engagement, and lifetime value outcomes; build roadmaps, business cases, and AI-enabled experiences. Partner cross-functionally, run large-scale initiatives, and develop a team of Product Managers to improve customer experience and drive growth.

Lead stakeholder discovery and data-driven analysis for claims processes. Translate findings into system requirements, value propositions, business cases, and roadmap inputs. Document processes and requirements, perform cost-benefit and ROI analysis, partner with cross-functional teams, and communicate insights to influence decisions and support implementation.

Lead sourcing and category management for pharmaceutical and other supply categories. Develop multi-year sourcing pipelines, supplier segmentation, risk-adjusted savings forecasts, negotiate with vendors, ensure compliance, and partner with leadership and cross-functional teams to implement sourcing programs and supplier sustainability and compliance initiatives.