Program Integrity Contract Lead

Humana

5d • $94,900 - $130,500 • Remote

About The Position

The Program Integrity (PI) Contract Lead is an important member of the leadership team and works directly with Program Integrity Leadership, the Compliance Officer, and the Compliance Committee. This position requires a strong understanding of the VA Community Care Network (CCN) program, including, but not limited to, federal healthcare program requirements, Executive Order 12549, Federal Acquisition Regulation (FAR) Part 3, the Federal False Claims Act, and applicable state and federal laws governing program integrity and compliance.

The PI Contract Lead analyzes and evaluates the effectiveness of existing business processes and develops sustainable, repeatable, and measurable process improvements. You will participate in and influence departmental and cross-functional strategy discussions, recommending changes needed to maintain compliance with contractual obligations and regulatory requirements. You will address issues of varied scope and complexity, ranging from moderate to significant.
The PI Contract Lead works collaboratively with key stakeholders to provide consultative support, internal briefings, training, and participation in integrated care planning, as needed. You will partner with stakeholders to identify, develop, and implement corrective actions. Responsibilities include performing root cause analyses, escalating significant concerns to leadership, and recommending functional strategies to address identified risks or gaps. Decisions may involve resource allocation, operational approach, tactical execution, and department-level initiatives.

Administrative responsibilities include, but are not limited to, preparing and maintaining Contract Data Requirements List (CDRL) reports; managing the Program Integrity library, including letters, job aids, and process flow documentation; reviewing associate documentation and tools; analyzing data findings; and briefing the team on key results and recommendations. The PI Contract Lead also provides support to data and technology teams in the development of business and financial models.

Requirements

• 5 or more years of Program Integrity and/or Payment Integrity experience
• 2 or more years of project management (Ideally in implementing large contracts) experience
• Must have ONE of the following ant-fraud degrees, designations, and/or certifications: Registered Nurse/Bachelor of Science in Nursing (RN/BSN), Certified Profession 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), Juris Doctorate (JD)
• Current experience with understanding claims adjudication, systems and reporting
• Knowledge in healthcare related applications and technology
• Ability to manage and prioritize multiple initiatives with minimal guidance
• Excellent communication and presentation skills to include the ability to communicate and present technical details to senior and executive level leadership
• Results-driven mindset with the ability to achieve established individual and organizational goals
• Experienced in researching and analyzing data to determine root cause within areas of opportunity
• Experience reading and interpreting documents such as contracts, policy and operations manuals
• High level problem-solving and analytical experience
• Proficiency in Microsoft office suite Excel, PowerPoint and Word
• U.S. citizenship for this position
• Successfully receive approval for government security clearance (Via National Background Investigation Services NBIS)

Nice To Haves

• BA in Business, HealthCare Administration or Operations Management
• Lean Six Sigma and/or Project Management Experience/Certificate
• Knowledge and experience working with Government programs to include VA, Medicare and/or TRICARE
• Previous experience managing or leading programs, technical implementations and/or initiatives
• Prior experience with Workflow design and Business Process Optimization
• Ability to learn a complex processing system

Responsibilities

• Translate contract requirements into business processes, workflows, controls, procedures, and operational requirements.
• Develop implementation workplans, milestones, dependencies, risks and readiness criteria for projects.
• Identify operational gaps and recommend process changes necessary to meet contractual requirements.
• Support development of standard operating procedures, desk level procedures, workflows, job aids and training materials.
• Establish and maintain an ongoing contract monitoring framework to ensure continued compliance with contractual requirements.
• Monitor contract performance, service level agreements, key performance indicators, deliverables, milestones, and operational commitments.
• Apply Lean, Six Sigma, root cause analysis and other process improvement methodologies to improve operational and contract performance.
• Conduct routine reviews of contract requirements to ensure operational processes remain aligned with current contractual obligations.
• Preparing and maintaining Contract Data Requirements List (CDRL) reports.
• Managing the Program Integrity library, including letters, job aids, and process flow documentation.
• Reviewing associate documentation and tools.
• Analyzing data findings.
• Briefing the team on key results and recommendations.
• Provides support to data and technology teams in the development of business and financial models.

Benefits

• medical
• dental
• vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Manager