Payment Integrity Lead – Strategy & Audit Optimization

This is a fully remote position, open to applicants in United States.

📋 Description

• Discover new Payment Integrity and Data Mining opportunities by analyzing industry trends, reimbursement and policy changes, provider billing patterns, claims data, and portfolio performance.

• Track reimbursement trends for Medicare, Medicaid, and Commercial sectors.

• Investigate payment leakage and formulate hypotheses for innovative audit concepts.

• Stay informed about external Payment Integrity practices, technology, and analytical methods.

• Convert opportunities into clear audit concepts and testable business hypotheses.

• Outline concept intent, claims population, anticipated payment behavior, policy rationale, initial logic, and financial opportunity.

• Collaborate with analytical, clinical, coding, policy, technology, and operational teams to test and validate concepts.

• Assess results and suggest whether to advance, modify, scale, or discontinue concepts.

• Guide concepts from inception through validation and implementation.

• Influence cross-functional partners without having direct authority.

• Address barriers and establish ownership, milestones, dependencies, and success metrics.

• Present recommendations to leaders and stakeholders.

• Analyze existing concepts to enhance accuracy, financial performance, uphold rates, efficiency, and provider experience.

• Identify and address unnecessary rework, disputes, appeals, overturns, and administrative costs.

• Suggest refining, automating, moving upstream, consolidating, or retiring concepts.

• Inform Payment Integrity leadership about emerging opportunities, portfolio performance, and industry trends.

• Provide executive-level recommendations backed by claims analysis, financial implications, operational considerations, and risk assessment.

• Lead complex initiatives involving analytical, operational, clinical, technology, and business stakeholders.

• Mentor team members involved in opportunity identification, concept development, testing, and optimization.

• Work remotely from home with occasional travel to Humana offices for training or meetings.

• Adjust work schedule to align with Eastern Standard Time business hours as necessary.

⛳️ Requirements

• Over 8 years of experience in healthcare, Payment Integrity, claims, reimbursement, auditing, healthcare analytics, payment policy, or related fields.

• Proven experience in interpreting healthcare claims and understanding reimbursement methodologies, payment policies, coding, contracts, or benefit requirements.

• In-depth knowledge of the healthcare payer environment and the end-to-end claims lifecycle.

• Capability to identify opportunities from data, industry developments, claims patterns, or business trends and translate findings into actionable recommendations.

• Experience in developing, testing, implementing, or optimizing healthcare payment, audit, claims, or analytical concepts.

• Ability to independently navigate complex and ambiguous business challenges.

• Strong analytical and critical-thinking skills.

• Proficiency in evaluating financial opportunities, operational feasibility, risk, and business impact.

• Aptitude for leading complex initiatives across multiple teams without direct reporting authority.

• Constructively challenge existing processes and assumptions.

• Excellent executive communication skills.

• Skilled in managing multiple high-priority initiatives and measurable outcomes.

• Advanced proficiency in Excel, PowerPoint, and other analytical and communication tools.

• Sound independent judgment and decision-making abilities.

• Commitment to confidentiality and proper handling of healthcare and business information.

• Preferred: extensive experience in Payment Integrity, Data Mining, claims auditing, medical cost management, Special Investigations, Fraud, Waste & Abuse, revenue recovery, or healthcare payment analytics.

• Preferred: experience in developing innovative healthcare claims audit or Payment Integrity concepts through to implementation.

• Preferred: familiarity 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 working with large claims datasets or analytical tools.

• Preferred: experience evaluating concept performance based on savings, yield, accuracy, uphold/overturn rates, disputes, appeals, recoverability, and operational costs.

• Preferred: experience in developing business cases or financial opportunity estimates.

• Preferred: experience in progressing 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 advantageous.

• 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 required.

• A dedicated workspace without ongoing interruptions to safeguard member PHI/HIPAA information is necessary.

🏝️ 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 from home.

• Flexible scheduling aligned to the associate's home time zone and EST as necessary.