Job Details
Clinical Policy Operations Professional 2
**Become a part of our caring community**
The Clinical Policy Operations Professional 2 provides operational support to clinical pharmacists for the implementation, maintenance, submission, and ongoing management of clinical policies, drug lists, and benefit requirements. This role focuses on accurately translating approved clinical strategies into operational systems and tools, requiring strong attention to detail, independent problem solving, and consistent execution within established processes.
The Clinical Policy Operations Professional 2 ensures accuracy and compliance for utilization management (UM) criteria within the Clinical Policy System, operational guidance documentation, and the submission and maintenance of policies provided to external accreditation and review bodies. They collaborate with healthcare professionals, pharmacists, and business stakeholders to operationalize clinical policy strategies and perform quality analysis and reporting to ensure effective operational execution.
This role creates process and training documentation as appropriate. They understand department, and organizational strategy and operating objectives, including their linkages to related areas. They make decisions regarding their own work methods, occasionally in ambiguous situations, and require minimal direction while seeking guidance when needed. They follow established guidelines and procedures. Success in this role requires strong attention to detail, comfort working within established processes, sound judgement, and the ability to manage recurring operational responsibilities with a high degree of accuracy.
+ Collaborates with Clinical Subject Matter Experts to translate complex clinical recommendations into standardized policy criteria and operational requirements within formulary and clinical policy systems.
+ Interprets Medicare and state-specific Medicaid regulations, benefit requirements, and operational guidance to support the accurate implementation and maintenance of state-specific clinical policies and utilization management strategies
+ Partners with clinical, operational, and business stakeholders to ensure clinical policy intent is accurately reflected in formulary structures, utilization management criteria, and system configuration. Performs detailed reviews to ensure policy configurations and operational guidance align with approved clinical and business requirements
+ Supports cross-functional efforts related to policy implementation, operational processes, and workflow management across clinical and business teams
+ Participates in cross-functional initiatives to streamline policy implementation, workflow management, and operational review processes across clinical and operational teams.
**Use your skills to make an impact**
**Required Qualifications**
+ Bachelor's degree
+ Less than 5 years of technical experience
+ Strong collaboration and relationship-building skills
+ Excellent written and verbal communication skills
+ Excellent planning and organizational skills
+ Demonstrated ability to manage complex operational processes requiring a high degree of accuracy, attention to detail, and independent problem solving
+ Working knowledge of all Microsoft Office applications, including Word, Excel and Outlook
+ Ability to work on multiple, competing projects
+ Ability to successfully handle change in a fast-paced environment
+ Must be passionate about contributing to an organization focused on continuously improving consumer experiences
+ Proven ability to collaborate across departments and lines of business to support alignment and operational execution
**Preferred Qualifications**
+ Experience with data analysis, reporting, and process measurement tools (e.g., Excel, Access, Power BI)
+ Previous experience in pharmacy benefits management or healthcare operations
+ Experience supporting Medicare and/or managed Medicaid programs
+ Experience working in cross-functional operational, policy, or implementation environments
**Additional Information:**
As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
**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.
Satellite, cellular and microwave connection can be used only if approved by leadership.
Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
**SSN Alert:**
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
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 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
Application Deadline: 07-12-2026
**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.
?
**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.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
The Clinical Policy Operations Professional 2 provides operational support to clinical pharmacists for the implementation, maintenance, submission, and ongoing management of clinical policies, drug lists, and benefit requirements. This role focuses on accurately translating approved clinical strategies into operational systems and tools, requiring strong attention to detail, independent problem solving, and consistent execution within established processes.
The Clinical Policy Operations Professional 2 ensures accuracy and compliance for utilization management (UM) criteria within the Clinical Policy System, operational guidance documentation, and the submission and maintenance of policies provided to external accreditation and review bodies. They collaborate with healthcare professionals, pharmacists, and business stakeholders to operationalize clinical policy strategies and perform quality analysis and reporting to ensure effective operational execution.
This role creates process and training documentation as appropriate. They understand department, and organizational strategy and operating objectives, including their linkages to related areas. They make decisions regarding their own work methods, occasionally in ambiguous situations, and require minimal direction while seeking guidance when needed. They follow established guidelines and procedures. Success in this role requires strong attention to detail, comfort working within established processes, sound judgement, and the ability to manage recurring operational responsibilities with a high degree of accuracy.
+ Collaborates with Clinical Subject Matter Experts to translate complex clinical recommendations into standardized policy criteria and operational requirements within formulary and clinical policy systems.
+ Interprets Medicare and state-specific Medicaid regulations, benefit requirements, and operational guidance to support the accurate implementation and maintenance of state-specific clinical policies and utilization management strategies
+ Partners with clinical, operational, and business stakeholders to ensure clinical policy intent is accurately reflected in formulary structures, utilization management criteria, and system configuration. Performs detailed reviews to ensure policy configurations and operational guidance align with approved clinical and business requirements
+ Supports cross-functional efforts related to policy implementation, operational processes, and workflow management across clinical and business teams
+ Participates in cross-functional initiatives to streamline policy implementation, workflow management, and operational review processes across clinical and operational teams.
**Use your skills to make an impact**
**Required Qualifications**
+ Bachelor's degree
+ Less than 5 years of technical experience
+ Strong collaboration and relationship-building skills
+ Excellent written and verbal communication skills
+ Excellent planning and organizational skills
+ Demonstrated ability to manage complex operational processes requiring a high degree of accuracy, attention to detail, and independent problem solving
+ Working knowledge of all Microsoft Office applications, including Word, Excel and Outlook
+ Ability to work on multiple, competing projects
+ Ability to successfully handle change in a fast-paced environment
+ Must be passionate about contributing to an organization focused on continuously improving consumer experiences
+ Proven ability to collaborate across departments and lines of business to support alignment and operational execution
**Preferred Qualifications**
+ Experience with data analysis, reporting, and process measurement tools (e.g., Excel, Access, Power BI)
+ Previous experience in pharmacy benefits management or healthcare operations
+ Experience supporting Medicare and/or managed Medicaid programs
+ Experience working in cross-functional operational, policy, or implementation environments
**Additional Information:**
As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
**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.
Satellite, cellular and microwave connection can be used only if approved by leadership.
Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
**SSN Alert:**
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
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 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
Application Deadline: 07-12-2026
**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.
?
**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.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
Job #NLX294127545