Payment Integrity Professional 2

Humana

3d•$65,000 - $88,600•Remote

About The Position

The Payment Integrity Professional 2 leverages claims data, vendor platforms, and analytic tools to identify trends, perform root cause analysis, and develop mitigation strategies that support accurate payment outcomes. This role collaborates with internal stakeholders and external code edit vendors to support pre and post implementation code editing functions. The position contributes directly to cost reduction and improved payment accuracy through data driven insights and operational execution. The Payment Integrity Professional 2 leverages claims data, vendor platforms, and analytic tools to identify trends, perform root cause analysis, and develop mitigation strategies that support accurate payment outcomes. This role collaborates with internal stakeholders and external code edit vendors to support pre and post implementation code editing functions. The position contributes directly to cost reduction and improved payment accuracy through data driven insights and operational execution.

Requirements

Strong analytical skills with the ability to interpret data and identify trends
Experience conducting root‑cause analysis and developing mitigation or corrective action plans
Ability to manage multiple priorities and shift tasks quickly based on urgency
Working knowledge of Microsoft Word, SharePoint, and Excel
Comfortable making decisions in a dynamic, fast‑changing environment
Advanced problem‑solving skills, including critical thinking and collaboration
Ability to work independently and in a team with minimal supervision
High attention to detail and accuracy
Strong written and verbal communication skills
Ability to work in a fast‑paced environment
Commitment to confidentiality, ethical practice, and professional integrity

Nice To Haves

Experience using CAS
Experience with code edit tools such as: Rialtic Provider Inquiries Tool ClaimsXten Web UI Cotiviti What If Tool (WIT) Optum CES Cotiviti Claims Inquiry Tool (CIT) Nucleus KnowledgeSource
Experience analyzing medical claims data and interpreting payment outcomes
Experience with Humana code edit processes
Experience working with internal stakeholders and external vendors
Familiarity with PowerPoint and OneNote
Experience with THOR rule creation and/or maintenance
Experience leading projects or process‑improvement initiatives
Prior experience in Claims Administration and Payment Integrity (CAPI/CCM)

Responsibilities

Analyze medical claims data to identify trends, anomalies, and performance patterns related to code editing and payment accuracy
Conduct root‑cause analysis on incorrect payment outcomes and develop actionable mitigation plans
Support the review, testing, implementation, and maintenance of code edits, using data to validate expected outcomes
Partner with internal stakeholders and external vendors to translate analytic findings into operational improvements
Investigate and resolve code edit stakeholder inquiries through data research, issue analysis, and evidence‑based recommendations
Monitor key performance metrics, identify operational risks, and proactively recommend improvements
Drive process optimization and contribute to successful day-to-day operations
Document findings, maintain reports, and communicate results to technical and non‑technical audiences