Full-Time
Associate Vice President, Medical Risk Adjustment and Provider Engagement
National Medical Director
Humana
10,001+ employees
Medicare Advantage health insurer for seniors
Compensation Overview
$246.1k - $344.2k/yr
Remote in USA
Remote
Occasional travel to Humana offices for training or meetings may be required.
MD
 Medical, Clinical & Veterinary (1) |
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- An advanced clinical degree (MD or DO) is required.
- Demonstrated experience in clinical leadership roles, preferably within managed care, risk adjustment, or quality improvement environments.
- Experience with risk adjustment and STARS.
- Proven ability to lead and develop high-performing teams.
- Strong communication and relationship-building skills with experience engaging provider organizations.
- Experience developing and monitoring key performance indicators, reporting, and educational programs for healthcare leaders.
- Proficiency in interpreting clinical and quality data to drive performance improvement.
- A dedicated home workspace without ongoing interruptions is required to protect member protected health information and HIPAA information.
- A home internet connection with at least 25 Mbps download and 10 Mbps upload speed is required.
- Provide clinical guidance and subject matter expertise across all STARS and risk adjustment initiatives to ensure alignment with organizational objectives and regulatory requirements.
- Demonstrate responsiveness to providers to increase provider engagement and satisfaction related to risk adjustment and clinical quality programs.
- Serve as the overseeing medical director for STARS self-reporting metrics, including clinical oversight, interpretation, and escalation of issues requiring physician leadership.
- Participate in Centers for Medicare & Medicaid Services audits related to STARS and risk adjustment activities, providing physician-level clinical expertise alongside technical and operational audit support.
- Provide targeted provider education on clinical and operational areas needed to close STARS gaps and improve performance on quality measures.
- Lead and manage a team supporting risk adjustment education, ensuring that materials and communications are accurate, timely, and effective.
- Develop, implement, and monitor key performance indicators for Regional Vice Presidents and Health Services Directors, ensuring that performance metrics, reporting processes, and educational initiatives support continuous improvement in risk adjustment outcomes and provider engagement.
- Collaborate cross-functionally with operations, clinical, analytics, and compliance teams to drive initiative success.
- Oversee the design and delivery of education sessions, materials, and resources for internal teams and provider partners.
- Analyze data and trends to identify opportunities for process improvements and enhanced provider engagement strategies.
- Ensure that risk adjustment activities comply with applicable regulations, internal policies, and quality standards.
- Serve as the physician signatory for provider disclosure letters related to risk adjustment when Humana modifies a claim with a new diagnosis, ensuring communications are clinically appropriate and compliant.
- Assist with provider reporting, provider education, and feedback loops to support accurate documentation, improved STARS performance, and compliant risk adjustment practices.
- Clinical leadership experience within managed care, risk adjustment, or quality improvement environments.
Humana focuses on health and well-being by offering Medicare Advantage plans (HMO, PPO, and PFFS) mainly for seniors, military personnel, and communities. Its products are health insurance plans funded through a mix of government contracts and member premiums, enrolling members to provide comprehensive coverage with flexible benefits and a broad provider network. Members receive care through a network of providers, with additional services such as free language interpretation to improve accessibility. Humana differentiates itself through its emphasis on inclusivity, accessibility, and tailored benefits, aiming to deliver reliable service and high renewal rates. The goal is to improve health outcomes and overall well-being for members by delivering coverage that meets diverse needs and making care accessible to all.
Company Size
10,001+
Company Stage
IPO
Headquarters
Louisville, Kentucky
Founded
1961
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Simplify's Take
What believers are saying
- Second-quarter 2026 revenue reached $40.87 billion, up 26.2%, beating estimates.
- Illinois awarded Humana a statewide Medicaid contract starting January 2027, broadening state footing.
- Humana expects 2027 MA membership growth of roughly 25%, despite plan exits.
What critics are saying
- CMS star-rating losses cut 2026 GAAP EPS guidance to at least $6.52.
- 2027 plan exits hit 600,000 members, risking churn and weaker brand trust.
- Texas appeal loss or further CMS downgrades can erase billions in MA bonuses.
What makes Humana unique
- Humana leads Medicare Advantage with 6.45 million individual MA members in 2026.
- CenterWell and Medicaid expansion add care delivery and government-contract diversification beyond insurance.
- August 2026 board adds Anthropic's Paul Smith, signaling faster AI-enabled care operations.
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Benefits
Health Insurance
Dental Insurance
Vision Insurance
Life Insurance
Disability Insurance
Unlimited Paid Time Off
Paid Vacation
Paid Parental Leave
Short-term Disability
Long-term Disability
401(k) Retirement Plan
401(k) Company Match
Wellness Program
Growth & Insights and Company News
6 month growth
↑ 6%1 year growth
↑ 6%2 year growth
↑ 6%Thyme Care, a Nashville-based oncology company, has closed a Series E funding round of more than $125 million at a valuation exceeding $2 billion. Morgan Health led the round, with participation from CVS Health Ventures, Humana, AlleyCorp, HealthQuest Capital, Foresite Capital, Concord Health Partners, Frist Cressey Ventures, Town Hall Ventures, and a16z Bio + Health. The company now serves over 10.5 million people across all 50 US states and manages more than $7 billion in oncology spend. Thyme Care reports it is profitable with positive free cash flow whilst delivering validated reductions of 5 to 10 per cent in total cost of care. Alongside the funding, Thyme Care is establishing Thyme Companies, a parent entity that will build a portfolio of independent oncology businesses addressing care barriers. Co-founder Robin Shah will serve as executive chairman of the new entity.
Humana has appointed Dr Shantanu Nundy as Chief Medical Officer, effective 31 August. Dr Nundy, a practicing physician and healthcare executive, will help shape the company's products, platforms, and use of AI whilst bringing clinical expertise to the enterprise. He most recently served as Executive Vice President of Care Delivery and Chief Health Officer at Accolade, a healthcare navigation company. Previously, he was Managing Director for Clinical Innovation at Evolent Health, driving value-based and digital care transformation across health systems. Dr Nundy will report to Jim Rechtin, Humana's President and CEO, and join the company's Enterprise Leadership Team. He continues to practice primary care and hospital medicine.
Humana reported Q2 revenues of $40.87 billion, up 26.2% year on year, exceeding analysts' expectations by 0.6%. The health insurance provider also beat earnings per share estimates. Despite the relatively strong results, Humana's stock has fallen 2.7% since the earnings announcement and currently trades at $378.11. The health insurance sector as a whole showed resilience in Q2, with the 12 tracked providers beating revenue consensus estimates by 2.8% on average. However, share prices across the sector have declined an average of 5.8% since reporting. Humana derives over 80% of its revenue from federal government contracts and serves approximately 17 million members, with a strong focus on Medicare Advantage plans for seniors.
Nearly 3 million older Americans will lose their Medicare Advantage plans this year, according to Johns Hopkins Bloomberg School of Public Health research. One in 10 Medicare Advantage policyholders face forced disenrollment, with Vermont hit hardest at 92% of policyholders affected. Humana announced its exit from multiple markets for the second consecutive year, impacting 600,000 members. The company reported $1.9 billion profit in the first half of 2026. Insurers cite financial pressures from federal policy changes aimed at reducing overpayments, resulting in lower government reimbursement rates. Combined with rising medical costs, these factors are squeezing profit margins. Shannon Benton of Senior Citizens League said Humana's decision shows Medicare Advantage insurers are "prioritising profit growth over enrollment growth.
Nine pharmacy benefit managers will integrate TrumpRx prescription drug pricing into their benefit tools, effective 1 January 2027. The Pharmaceutical Care Management Association and participating PBMs—including CVS Health, Express Scripts, Humana, and OptumRx—will display cash prices from TrumpRx alongside plan coverage costs. The agreement covers commercial, Medicare, and Medicaid plans. Patients will see TrumpRx prices for all listed drugs, whether through presidential deals or standard pricing. CMS Administrator Dr Mehmet Oz said the commitment will help patients compare prices and find better deals. PCMA CEO David Marin stated the transparency will allow consumers to make better-informed choices about prescription drug costs. Some PBMs will use Real Time Benefit Tools to display pricing comparisons, whilst others may employ different methods.