Program Integrity Contract Lead

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

📋 Description

• Collaborate directly with Program Integrity leadership, the Compliance Officer, and the Compliance Committee.

• Assess and enhance current business processes to create sustainable, repeatable, and measurable advancements.

• Engage in and shape both departmental and cross-functional strategic discussions.

• Suggest modifications to ensure adherence to contractual obligations and regulatory standards.

• Offer consultative assistance, internal briefings, training, and involvement in integrated care planning.

• Identify, create, and implement corrective actions in collaboration with stakeholders.

• Conduct root cause analyses and elevate significant issues to leadership.

• Propose functional strategies to mitigate risks and address gaps.

• Prepare and sustain Contract Data Requirements List (CDRL) reports.

• Oversee the Program Integrity library, which includes letters, job aids, and process flow documentation.

• Review documentation and tools created by associates.

• Analyze data findings and present key results and recommendations to the team.

• Assist data and technology teams in creating business and financial models.

• Convert contract requirements into business processes, workflows, controls, procedures, and operational criteria.

• Develop implementation work plans, milestones, dependencies, risks, and readiness indicators.

• Identify operational deficiencies and recommend process adjustments.

• Aid in the creation of standard operating procedures, desk-level procedures, workflows, job aids, and training materials.

• Establish and uphold a contract monitoring framework.

• Track contract performance, service level agreements, key performance indicators, deliverables, milestones, and operational commitments.

• Utilize Lean, Six Sigma, root cause analysis, and other methodologies for process improvement.

• Conduct regular reviews to ensure operational processes align with contractual obligations.

⛳️ Requirements

• A minimum of 5 years experience in Program Integrity and/or Payment Integrity.

• At least 2 years of project management experience, preferably with large contract implementations.

• Must possess one of the following: 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 knowledge of claims adjudication, systems, and reporting.

• Familiarity with healthcare-related applications and technology.

• Ability to effectively manage and prioritize multiple initiatives with minimal supervision.

• Exceptional communication and presentation skills, particularly in conveying technical details to senior and executive leadership.

• Results-oriented mindset with a proven ability to meet established goals.

• Experience in researching and analyzing data to identify root causes.

• Proficiency in reading and interpreting contracts, policies, and operational manuals.

• High-level analytical and problem-solving abilities.

• Proficient in Microsoft Office Suite, including Excel, PowerPoint, and Word.

• U.S. citizenship is required.

• Must successfully obtain approval for government security clearance through National Background Investigation Services (NBIS).

• Candidates residing in Puerto Rico are not eligible for this government contract.

• A dedicated workspace free from interruptions to safeguard member PHI/HIPAA information.

• Home internet service with a minimum of 25 Mbps download and 10 Mbps upload speed.

• Preferred: Bachelor's degree in Business, Healthcare Administration, or Operations Management.

• Preferred: Lean Six Sigma and/or Project Management experience/certificate.

• Preferred: Understanding and experience with government programs including VA, Medicare, and/or TRICARE.

• Preferred: Previous leadership experience in program, technical implementation, and/or initiatives.

• Preferred: Experience in workflow design and business process optimization.

• Ability to master a complex processing system.

🏝️ Benefits

• Bonus incentive plan based on individual and/or company 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 coverage.

• Life insurance.

• Remote work arrangement.

• Occasional travel to Humana offices for training or meetings.