Become a part of our caring community and help us put health first

The Associate VP, Resolution- CTM Oversight and Operations will serve as a strategic leader overseeing initiatives to improve CMS STAR ratings and manage Complaint Tracking Metrics (CTMs) across insurance operations. This role is responsible for driving process improvements, ensuring compliance, and leading a large team to elevate member and provider experiences. The position has significant financial impact, directly influencing key business outcomes and organizational strategy.

• Track, analyze, and report on grievance, appeal, and complaint metrics to identify trends and drive continuous improvement.
• Lead efforts to reduce member and provider complaints, influencing changes across insurance operations for higher quality and operational efficiency.
• Ensure enrollment and claims processes comply with regulatory requirements and guidelines.
• Partner with cross-functional teams to investigate operational issues, determine root causes, implement corrective actions, and validate resolution.
• Identify and implement process improvements to enhance efficiency, member satisfaction, and regulatory compliance.
• Oversee resolution of member enrollment issues, claim disputes, and other reconciliation needs, especially during the Annual Enrollment Period (AEP).
• Utilize tools such as Availity to streamline claims submission, eligibility verification, and authorization processes.
• Directly lead a team of 7 associates, with oversight of an organization totaling 87 professionals.
• Influence enterprise-wide decisions to reduce CMS complaints and achieve a 5-star STARs rating, impacting approximately $300M in annual revenue.
• Collaborate with peer leaders in Risk Management and Grievances & Appeals to implement best practices and ensure timely, equitable resolution of issues.

Use your skills to make an impact

Required Qualifications

• Bachelor’s degree
• 10 plus years’ experience in health insurance operations, complaint management, and CMS STARs programs (experience in large national insurers strongly preferred).
• 6 plus years’ leadership experience in cross-functional and strategic process improvement roles.
• Deep understanding of compliance, regulatory requirements, and quality metrics in managed care.
• Strong analytical and communication skills, with the ability to convey complex ideas clearly to diverse audiences.
• Confidence, poise, and the ability to lead aggressive improvements in STARs performance.

Preferred Qualifications

• Master’s degree
• CTM experience with a large carrier, strongly preferred

Additional Information

• 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.
• Humana offers a variety of benefits to promote the best health and well-being of our employees and their families. We design competitive and flexible packages to give our employees a sense of financial security—both today and in the future, including:
  
  Health benefits effective day 1
  Paid time off, holidays, volunteer time and jury duty pay
  Recognition pay
  401(k) retirement savings plan with employer match
  Tuition assistance
  Scholarships for eligible dependents
  Parental and caregiver leave
  Employee charity matching program
  Network Resource Groups (NRGs)
  Career development opportunities

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.

$203,400 - $279,800 per year

This 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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About Us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large.

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.