Payment Integrity Lead - Strategy & Audit Optimization

Humana

1d • $94,900 - $130,500 • Remote

About The Position

The Payment Integrity Lead - Strategy & Audit Optimization is a strategic leadership role focused on identifying, evaluating, testing, and advancing new Payment Integrity opportunities that produce sustainable medical cost savings. The role uses technology, data mining, claims analysis, and knowledge of healthcare reimbursement to detect anomalies, identify potential overpayments, support financial recovery, and develop new audit concepts.

The Lead monitors industry developments, regulatory and reimbursement changes, payment policies, claims patterns, provider behaviors, and portfolio performance to identify actionable opportunities. With significant independence, the role develops hypotheses, assesses financial opportunity and operational feasibility, tests concepts, and influences cross-functional partners to operationalize successful strategies across Prepay and Postpay Payment Integrity. The work includes optimizing existing audits, improving accuracy and efficiency, addressing disputes and administrative costs, and recommending that concepts be refined, automated, moved upstream, consolidated, or retired.

The position works across analytical, clinical, coding, policy, technology, operational, and business teams, often without direct authority over their resources. It provides executive-level recommendations supported by claims analysis, financial impact, operational considerations, and risk assessment; leads complex initiatives; and helps foster experimentation, accountability, and continuous improvement. The role is remote, with occasional travel to Humana offices for training or meetings. Typical hours are Monday through Friday in the associate's home time zone, with schedule alignment to Eastern Time business hours as needed.

Requirements

• At least 8 years of experience in healthcare, Payment Integrity, claims, reimbursement, audit, healthcare analytics, payment policy, or a related area.
• Experience interpreting healthcare claims and understanding how reimbursement methodologies, payment policies, coding, contracts, or benefit requirements affect claim payment.
• Strong knowledge of the healthcare payer environment and end-to-end claims lifecycle.
• Ability to identify opportunities from data, industry developments, claims patterns, or business trends and translate findings into actionable recommendations.
• Experience developing, testing, implementing, or optimizing healthcare payment, audit, claims, or analytical concepts.
• Ability to independently navigate complex, ambiguous business problems without a predefined solution or path forward.
• Strong analytical and critical-thinking skills, including the ability to evaluate financial opportunity, operational feasibility, risk, and business impact.
• Ability to lead complex initiatives and drive results across multiple teams without direct reporting authority.
• Ability to challenge existing processes and assumptions constructively and recommend alternatives supported by data and business rationale.
• Strong executive communication skills and ability to translate detailed claims, analytical, or reimbursement findings into concise business recommendations.
• Ability to manage multiple high-priority initiatives while maintaining accountability for milestones and measurable outcomes.
• Advanced proficiency with Excel, PowerPoint, and other tools used to analyze information and communicate complex findings.
• Sound independent judgment and decision-making on complex business issues.
• Commitment to confidentiality and appropriate handling of healthcare and business information.

Nice To Haves

• Deep experience in Payment Integrity, Data Mining, claims audit, medical cost management, Special Investigations, Fraud, Waste & Abuse, revenue recovery, or healthcare payment analytics.
• Experience identifying and developing new healthcare claims audit or Payment Integrity concepts from initial hypothesis through implementation.
• Experience with both Prepay and Postpay Payment Integrity strategies.
• Strong understanding of Medicare, Medicaid, and/or Commercial reimbursement methodologies.
• Knowledge of CMS reimbursement methodologies, coding guidance, healthcare payment policies, provider billing practices, and emerging industry trends.
• Experience using large claims datasets or analytical tools to identify patterns, outliers, payment leakage, or potential concept opportunities.
• Experience evaluating concept performance using measures such as savings, yield, accuracy, uphold or overturn rates, provider disputes, appeals, recoverability, and operational cost.
• Experience developing business cases or financial opportunity estimates for new Payment Integrity initiatives.
• Experience taking concepts through ideation, analysis, testing, validation, implementation, and ongoing optimization.
• Experience influencing senior leaders and cross-functional stakeholders on complex or potentially controversial recommendations.
• Experience supporting organizational medical cost savings or cost-of-care initiatives.
• Familiarity with Payment Integrity technology platforms, claims systems, data mining solutions, and/or advanced analytics.
• Experience with healthcare claims modernization, automation, machine learning, or AI-enabled Payment Integrity solutions.
• Project management, Lean, Six Sigma, healthcare coding, auditing, clinical, or related professional certification.

Responsibilities

• Identify new Payment Integrity and Data Mining opportunities by analyzing industry trends, reimbursement and policy changes, provider billing patterns, claims data, and portfolio performance.
• Monitor Medicare, Medicaid, and Commercial reimbursement trends for changes that may create Payment Integrity opportunities.
• Research potential payment leakage and develop hypotheses for new audit concepts, including opportunities outside existing processes.
• Maintain awareness of external Payment Integrity practices, technologies, and analytical approaches.
• Translate opportunities into defined audit concepts and testable business hypotheses, including concept intent, claims population, expected payment behavior, policy rationale, preliminary logic, and expected financial opportunity.
• Partner with analytical, clinical, coding, policy, technology, and operational teams to test and validate concepts.
• Evaluate test results and recommend whether concepts should be advanced, modified, scaled, or discontinued.
• Drive promising concepts from ideation through validation and implementation, establishing accountability and momentum across teams.
• Influence cross-functional partners, resolve barriers, and establish ownership, milestones, dependencies, and success measures.
• Communicate recommendations clearly to leaders and stakeholders, including recommendations that challenge existing processes or assumptions.
• Evaluate existing concepts for improvements in accuracy, financial performance, uphold rates, efficiency, and provider experience.
• Identify concepts causing unnecessary rework, disputes, appeals, overturns, or administrative expense and determine appropriate remediation.
• Recommend refining, automating, moving upstream, consolidating, or retiring concepts based on performance data.
• Advise Payment Integrity leadership on emerging opportunities, portfolio performance, and industry developments.
• Provide concise executive-level recommendations supported by claims analysis, financial impact, operational considerations, and risk assessment.
• Lead complex initiatives involving analytical, operational, clinical, technology, and business stakeholders.
• Mentor others in opportunity identification, concept development, testing, and optimization, and help promote curiosity, experimentation, calculated risk-taking, accountability, and continuous improvement.

Benefits

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off and company and personal holidays.
• Paid parental and caregiver leave.
• Short-term and long-term disability insurance.
• Life insurance.
• Bonus incentive plan based on company and/or individual performance.
• Bi-weekly payment for internet expenses for associates working from home in California, Illinois, Montana, or South Dakota.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed