Program Integrity Contract Lead

Job not on LinkedIn

🔥 2 minutes ago

🇺🇸 United States – Remote

💵 $94.9k - $130.5k / year

⏰ Full Time

🟠 Senior

🦅 H1B Visa Sponsor

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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

• Work directly with Program Integrity leadership, the Compliance Officer and the Compliance Committee • Analyze and evaluate existing business processes and develop sustainable, repeatable and measurable improvements • Participate in and influence departmental and cross-functional strategy discussions • Recommend changes to maintain compliance with contractual obligations and regulatory requirements • Provide consultative support, internal briefings, training and participation in integrated care planning • Identify, develop and implement corrective actions with stakeholders • Perform root cause analyses and escalate significant concerns to leadership • Recommend functional strategies to address risks and gaps • Prepare and maintain Contract Data Requirements List (CDRL) reports • Manage the Program Integrity library, including letters, job aids and process flow documentation • Review associate documentation and tools • Analyze data findings and brief the team on key results and recommendations • Support data and technology teams in developing business and financial models • Translate contract requirements into business processes, workflows, controls, procedures and operational requirements • Develop implementation workplans, milestones, dependencies, risks and readiness criteria • Identify operational gaps and recommend process changes • Support development of standard operating procedures, desk-level procedures, workflows, job aids and training materials • Establish and maintain a contract monitoring framework • Monitor contract performance, service level agreements, key performance indicators, deliverables, milestones and operational commitments • Apply Lean, Six Sigma, root cause analysis and other process improvement methodologies • Conduct routine reviews to keep operational processes aligned with contractual obligations

🎯 Requirements

• 5 or more years of Program Integrity and/or Payment Integrity experience • 2 or more years of project management experience, ideally implementing large contracts • Must have one of: Registered Nurse/Bachelor of Science in Nursing (RN/BSN), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS), Certification in Healthcare Compliance (CHC), Health Care Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or Juris Doctorate (JD) • Current experience understanding claims adjudication, systems and reporting • Knowledge of healthcare-related applications and technology • Ability to manage and prioritize multiple initiatives with minimal guidance • Excellent communication and presentation skills, including communicating technical details to senior and executive leadership • Results-driven mindset and ability to achieve established goals • Experience researching and analyzing data to determine root cause • Experience reading and interpreting contracts, policies and operations manuals • High-level problem-solving and analytical experience • Proficiency in Microsoft Office Suite, Excel, PowerPoint and Word • U.S. citizenship required • Must successfully receive approval for government security clearance via National Background Investigation Services (NBIS) • Candidates currently living in Puerto Rico cannot be hired for this government contract • Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information • Home internet service with at least 25 Mbps download and 10 Mbps upload • Preferred: BA in Business, Healthcare Administration or Operations Management • Preferred: Lean Six Sigma and/or Project Management experience/certificate • Preferred: Knowledge and experience with government programs including VA, Medicare and/or TRICARE • Preferred: Previous program, technical implementation and/or initiative leadership experience • Preferred: Workflow design and business process optimization experience • Ability to learn a complex processing system

🏖️ Benefits

• Bonus incentive plan based upon company and/or individual performance • Medical, dental and vision benefits • 401(k) retirement savings plan • Paid time off • Company and personal holidays • Paid parental and caregiver leave • Short-term and long-term disability • Life insurance • Remote work arrangement • Occasional travel to Humana offices for training or meetings