VP, Medicaid Clinical Economics & Quality

Vice President, Medicaid Clinical Economics & Quality

The Vice President, Medicaid Clinical Economics & Quality provides strategic and operational leadership for clinical effectiveness within the Medicaid segment. This function integrates Medical Economics, Clinical Insights, and Quality to deliver improved health outcomes, optimized cost performance and measurable program value across Medicaid. This executive leverages advanced analytical, data science, and leadership capabilities to optimize medical cost management, drive program performance, and support compliant operations. This VP will partner with segment leaders and cross-functional teams to develop evidence-based strategies and ensure the delivery of value-based, high-quality care to Medicaid members.

This role sits at the intersection of analytics, program effectiveness, and quality improvement for the Medicaid segment. Functions reporting to this leader include Medical Economics (medical cost analysis, premium analytics, program effectiveness and performance scorecards), Clinical Insights (population health, SDOH, behavioral health, pharmacy strategy, care management strategy), and Quality (withhold management, HEDIS management, value-based payment strategy, audits, and NCQA accreditations). The leader may be a data scientist, financial analyst, economist, or other analytical professional; though experience in Medicaid or government healthcare programs is essential. The ideal candidate will be a results-oriented, get-stuff-done (GSD) leader who can translate complex analytics into enterprise strategy and execution.

Key responsibilities include :

• Lead medical cost analysis, premium analytics, and program effectiveness initiatives for Medicaid products.
• Oversee the creation and tracking of performance scorecards and financial metrics to optimize segment outcomes.
• Collaborate with actuarial, finance, and clinical teams to interpret data and inform executive decisions.
• Direct population health strategy, including analysis of Social Determinants of Health (SDOH) and behavioral health trends.
• Guide pharmacy and care management strategies using data-driven insights to improve member engagement and outcomes.
• Integrate analytical models and predictive tools to inform program design and measurement.
• Oversee quality management, including withhold management, HEDIS performance, Value-Based Payment (VBP) strategy, audits, and NCQA accreditation.
• Ensure compliance with Medicaid requirements and regulatory standards.
• Drive continuous improvement in clinical quality and member satisfaction through robust data analysis.
• Build, mentor, and lead multidisciplinary teams across analytics, economics, and quality functions.
• Foster partnerships with internal stakeholders, regulatory agencies, and external partners to advance clinical effectiveness initiatives.
• Serve as a strategic advisor to the executive team, translating complex analytics into actionable business insights.
• Drive execution excellence, ensuring strategies are implemented effectively and sustainably.
• Embed a culture of accountability, with transparent tracking of program effectiveness and outcomes.
• Deliver actionable insights that directly shape business and clinical operations.

Qualifications :

Scheduled Weekly Hours : 40

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.

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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.