Risk Management Lead

Job not on LinkedIn

🔥 3 minutes ago

🐎 Kentucky – Remote

🐎 Kentucky – Remote

💵 $104k - $143k / year

⏰ Full Time

🟠 Senior

🔒 Insurance

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.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.

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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

• Lead and coordinate research, investigation, and documentation of alleged claim payment errors for quarterly external audits and random audit oversight • Train, mentor, and support staff in preparing audit packages, written rebuttal responses, and audit-related documentation • Document root causes for confirmed errors, support corrective action planning, and monitor remediation efforts • Collaborate with internal business partners, delegated entities, and claims processing subcontractors on audit findings, disputes, operational impacts, and resolutions • Provide subject matter expertise for reviewing high-dollar claims, including investigation, escalation, and follow-up • Interpret contractual requirements and translate them into audit controls, procedures, workflows, and monitoring activities • Develop and support implementation workplans with milestones, dependencies, risks, and readiness criteria • Identify gaps and recommend process improvements to meet contractual obligations and improve audit readiness • Develop and maintain standard operating procedures, desk-level procedures, workflows, job aids, and training materials • Identify, monitor, and address systemic claims processing errors and related compliance risks • Contribute to risk management and audit reporting dashboards for leadership review • Summarize key findings and present actionable recommendations to leadership • Support special projects and initiatives as directed by leadership

🎯 Requirements

• Must successfully receive interim approval for government security clearance (NBIS – National Background Investigation Services) • 5+ years of experience in healthcare claims operations, claims audit, payment integrity, risk management, compliance, or a related healthcare environment • Strong knowledge of and experience applying reimbursement methodologies for Institutional and Professional claims • 2+ years of experience leading projects, processes, or teams • Experience researching and resolving claim payment errors, audit findings, and operational issues • Experience interpreting contract requirements, policies, and regulatory guidelines and translating them into operational processes, controls, and monitoring activities • Experience supporting external audits, internal audits, or compliance reviews • Knowledge of claims processing, payment integrity, root cause analysis, and corrective action methodologies • Experience developing and implementing corrective action plans, remediation activities, and process improvements • Strong analytical, organizational, and problem-solving skills • Strong written and verbal communication skills, including the ability to prepare reports, rebuttals, and leadership summaries • Proficiency in Microsoft Office, including Excel, Word, and PowerPoint • Bachelor's degree in business, healthcare administration, finance, or a related field (preferred) • Experience supporting VA CCN or other government healthcare contracts (preferred) • Experience working with delegated entities, subcontractors, or external business partners in support of claims oversight or audit activities (preferred) • Home internet service with at least 25 Mbps download and 10 Mbps upload • Ability to work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information

🏖️ Benefits

• Bonus incentive plan based on company and/or individual performance • Medical, dental, and 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 • Dedicated work-from-home space supporting PHI/HIPAA privacy • Remote work arrangement • Occasional travel to Humana offices for training or meetings may be required