Risk Management Lead

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

📋 Description

• Oversee and manage the research, investigation, and documentation of suspected claim payment errors for quarterly external audits and random audit oversight.

• Provide training, mentorship, and assistance to staff in the preparation of audit packages, written rebuttal responses, and documentation related to audits.

• Record root causes of confirmed errors, assist in corrective action planning, and track remediation efforts.

• Collaborate with internal business partners, delegated entities, and claims processing subcontractors regarding audit findings, disputes, operational impacts, and resolutions.

• Offer subject matter expertise in the review of high-dollar claims, which includes investigation, escalation, and follow-up procedures.

• Analyze contractual requirements and convert them into audit controls, procedures, workflows, and monitoring activities.

• Create and support the implementation of workplans that include milestones, dependencies, risks, and readiness criteria.

• Identify deficiencies and suggest process enhancements to fulfill contractual obligations and enhance audit readiness.

• Develop and maintain standard operating procedures, desk-level procedures, workflows, job aids, and training materials.

• Detect, monitor, and resolve systemic claims processing errors and associated compliance risks.

• Contribute to the risk management and audit reporting dashboards for review by leadership.

• Summarize significant findings and present actionable recommendations to leadership.

• Assist with special projects and initiatives as directed by leadership.

⛳️ Requirements

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

• 5+ years of experience in healthcare claims operations, claims auditing, payment integrity, risk management, compliance, or a similar healthcare context.

• In-depth knowledge of and experience in applying reimbursement methodologies for Institutional and Professional claims.

• 2+ years of experience leading projects, processes, or teams.

• Proven experience in researching and resolving claims payment errors, audit findings, and operational issues.

• Experience in interpreting contract requirements, policies, and regulatory guidelines, translating them into operational processes, controls, and monitoring activities.

• Background in supporting external audits, internal audits, or compliance reviews.

• Familiarity with claims processing, payment integrity, root cause analysis, and corrective action methodologies.

• Experience in developing and implementing corrective action plans, remediation efforts, and process enhancements.

• Excellent analytical, organizational, and problem-solving skills.

• Strong written and verbal communication skills, including the ability to prepare reports, rebuttals, and summaries for leadership.

• Proficiency in Microsoft Office applications, including Excel, Word, and PowerPoint.

• Bachelor's degree in business, healthcare administration, finance, or a related field (preferred).

• Experience in supporting VA CCN or other government healthcare contracts (preferred).

• Experience collaborating with delegated entities, subcontractors, or external business partners for claims oversight or audit activities (preferred).

• Access to home internet service with a minimum of 25 Mbps download and 10 Mbps upload speeds.

• Ability to work from a dedicated area without interruptions to safeguard 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 ensuring PHI/HIPAA privacy.

• Remote work arrangement.

• Occasional travel to Humana offices for training or meetings may be required.