Payment Integrity Lead – Strategy & Audit Optimization

🔥 1 minute ago

🇺🇸 United States – Remote

💵 $94.9k - $130.5k / year

⏰ Full Time

🟠 Senior

🧐 Strategy

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Humana is a healthcare company dedicated to making a positive impact on the health of individuals, communities, and the healthcare system as a whole. With a focus on putting health first, Humana serves a diverse range of populations, including seniors and the military, providing Medicare Advantage HMO, PPO, and PFFS plans. Humana is committed to fostering a culture of belonging and mutual respect, offering competitive and flexible benefits to ensure the financial security of its employees and their families. The company prides itself on creating an inclusive workplace where everyone has the opportunity to succeed.

📋 Description

• Identify net-new Payment Integrity and Data Mining opportunities through industry trends, reimbursement and policy changes, provider billing patterns, claims data, and portfolio performance • Monitor Medicare, Medicaid, and Commercial reimbursement trends • Research payment leakage and develop hypotheses for new audit concepts • Maintain awareness of external Payment Integrity practices, technology, and analytical approaches • Translate opportunities into defined audit concepts and testable business hypotheses • Define concept intent, claims population, expected payment behavior, policy rationale, preliminary logic, and financial opportunity • Partner with analytical, clinical, coding, policy, technology, and operational teams to test and validate concepts • Evaluate results and recommend advancing, modifying, scaling, or discontinuing concepts • Drive concepts from idea through validation and implementation • Influence cross-functional partners without direct authority • Resolve barriers and establish ownership, milestones, dependencies, and success measures • Communicate recommendations to leaders and stakeholders • Evaluate existing concepts to improve accuracy, financial performance, uphold rates, efficiency, and provider experience • Identify and remediate unnecessary rework, disputes, appeals, overturns, and administrative expense • Recommend refining, automating, moving upstream, consolidating, or retiring concepts • Advise Payment Integrity leadership on emerging opportunities, portfolio performance, and industry developments • Provide executive-level recommendations supported by claims analysis, financial impact, operational considerations, and risk assessment • Lead complex initiatives across analytical, operational, clinical, technology, and business stakeholders • Mentor others involved in opportunity identification, concept development, testing, and optimization • Work remotely from home with occasional travel to Humana offices for training or meetings • Align work schedule with Eastern Standard Time business hours as needed

🎯 Requirements

• 8+ years of healthcare, Payment Integrity, claims, reimbursement, audit, healthcare analytics, payment policy, or related experience • Demonstrated experience interpreting healthcare claims and understanding reimbursement methodologies, payment policies, coding, contracts, or benefit requirements • Strong knowledge of the healthcare payer environment and end-to-end claims lifecycle • Ability to identify opportunities from data, industry developments, claims patterns, or business trends and translate findings into actionable recommendations • Experience developing, testing, implementing, or optimizing healthcare payment, audit, claims, or analytical concepts • Ability to independently navigate complex and ambiguous business problems • Strong analytical and critical-thinking skills • Ability to evaluate financial opportunity, operational feasibility, risk, and business impact • Ability to lead complex initiatives across multiple teams without direct reporting authority • Ability to challenge existing processes and assumptions constructively • Strong executive communication skills • Ability to manage multiple high-priority initiatives and measurable outcomes • Advanced proficiency with Excel, PowerPoint, and other analysis and communication tools • Sound independent judgment and decision-making • Commitment to confidentiality and appropriate handling of healthcare and business information • Preferred: deep experience in Payment Integrity, Data Mining, claims audit, medical cost management, Special Investigations, Fraud, Waste & Abuse, revenue recovery, or healthcare payment analytics • Preferred: experience developing net-new healthcare claims audit or Payment Integrity concepts through implementation • Preferred: experience with Prepay and Postpay Payment Integrity strategies • Preferred: understanding of Medicare, Medicaid, and/or Commercial reimbursement methodologies • Preferred: knowledge of CMS reimbursement methodologies, coding guidance, healthcare payment policies, provider billing practices, and emerging industry trends • Preferred: experience using large claims datasets or analytical tools • Preferred: experience evaluating concept performance using savings, yield, accuracy, uphold/overturn rates, disputes, appeals, recoverability, and operational cost • Preferred: experience developing business cases or financial opportunity estimates • Preferred: experience taking concepts through ideation, analysis, testing, validation, implementation, and optimization • Preferred: experience influencing senior leaders and cross-functional stakeholders • Preferred: experience supporting medical cost savings or cost-of-care initiatives • Preferred: familiarity with Payment Integrity technology platforms, claims systems, data mining solutions, and/or advanced analytics • Experience with claims modernization, automation, machine learning, or AI-enabled Payment Integrity solutions is a plus • Project management, Lean, Six Sigma, healthcare coding, auditing, clinical, or related professional certification is preferred • Minimum download speed of 25 Mbps and upload speed of 10 Mbps • Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information

🏖️ Benefits

• Bonus incentive plan based on company and/or individual performance • Medical benefits • Dental benefits • Vision benefits • 401(k) retirement savings plan • Paid time off • Company holidays • Personal holidays • Paid parental leave • Paid caregiver leave • Short-term disability • Long-term disability • Life insurance • Internet expense payment for associates working from home in California, Illinois, Montana, or South Dakota • Telephone equipment provided for Home or Hybrid Home/Office associates • Remote work at home • Flexible scheduling aligned to the associate's home time zone and EST as needed

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume