Payment Integrity Lead - Strategy & Audit Optimization

Summary

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The Payment Integrity Lead uses technology and data mining, detects anomalies in data to identify and collect overpayment of claims. Contributes to the investigations of fraud waste and our financial recovery. The Payment Integrity Lead works on problems of diverse scope and complexity ranging from moderate to substantial.

The Payment Integrity Lead - Strategy & Audit Optimization is a strategic leadership role responsible for identifying, evaluating, and advancing new Payment Integrity opportunities that drive sustainable medical cost savings.

This role will serve as a key leader within Payment Integrity's Trend Bender and Data Mining strategy, proactively identifying emerging industry trends, regulatory and reimbursement changes, payment policies, claims patterns, provider behaviors, and new analytical opportunities that can be translated into actionable Payment Integrity concepts.

The Lead will operate with significant independence and is expected to work effectively in areas where the opportunity, solution, or path forward may not yet be clearly defined. This individual will move beyond identifying issues to developing hypotheses, assessing financial opportunity and operational feasibility, testing new concepts, and influencing cross-functional partners to operationalize successful ideas across Prepay and Postpay Payment Integrity.

Success in this role requires strong Payment Integrity and healthcare claims knowledge, intellectual curiosity, sound business judgment, comfort taking calculated risks, and the ability to turn ambiguous or emerging opportunities into measurable results.

This role directly supports the organization's top Payment Integrity goals, including net-new Data Mining trends, Trend Bender savings, concept optimization, audit effectiveness, and medical cost savings.

Key Responsibilities

New Opportunity & Trend Identification

+ Proactively identify net-new Payment Integrity and Data Mining opportunities through analysis of industry trends, reimbursement and policy changes, provider billing patterns, claims data, and portfolio performance.

+ Monitor Medicare, Medicaid, and Commercial reimbursement trends to identify changes that may create new Payment Integrity opportunities.

+ Independently research potential payment leakage and develop hypotheses for new audit concepts, including opportunities that do not fit existing processes.

+ Maintain awareness of external Payment Integrity practices, technology, and emerging analytical approaches that could strengthen Humana's strategy.

Concept Development & Testing

+ Translate identified opportunities into clearly defined audit concepts and testable business hypotheses.

+ Define 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 new concepts.

+ Evaluate results and recommend whether to advance, modify, scale, or discontinue concepts, balancing speed with validation so concepts are operationally sound and defensible.

Operationalization & Influence

+ Drive promising concepts from idea through validation and implementation, creating accountability and momentum across teams.

+ Influence partners across Payment Integrity and the broader organization without direct authority over required resources.

+ Resolve barriers to high-value concepts and establish clear ownership, milestones, dependencies, and success measures.

+ Communicate recommendations clearly to leaders and stakeholders, including when they challenge existing processes or assumptions.

Concept & Audit Optimization

+ Evaluate existing concepts for opportunities to improve accuracy, financial performance, uphold rates, efficiency, and provider experience.

+ Identify concepts generating unnecessary rework, disputes, appeals, overturns, or administrative expense and determine remediation.

+ Recommend opportunities to refine, automate, move upstream, consolidate, or retire concepts based on performance data, keeping resources focused on high-value, sustainable interventions.

Strategy & Leadership

+ Serve as a strategic thought partner to 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 spanning analytical, operational, clinical, technology, and business stakeholders.

+ Help build a culture of curiosity, experimentation, calculated risk-taking, accountability, and continuous improvement, and mentor others involved in opportunity identification, concept development, testing, and optimization.

Use your skills to make an impact

WORK STYLE: Remote, work at home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

WORK HOURS: Typical work hours are Monday-Friday in each associate's home time zone, but as many meetings are conducted on EST (Eastern Standard Time) business hours, this associate will need to align their schedule with EST as needed.

Required Qualifications

+ 8+ years of healthcare, Payment Integrity, claims, reimbursement, audit, healthcare analytics, payment policy, or related experience.

+ Demonstrated 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 the end-to-end claims lifecycle.

+ Demonstrated 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 and ambiguous business problems where the solution or path forward is not predefined.

+ Strong analytical and critical-thinking skills with demonstrated ability to evaluate financial opportunity, operational feasibility, risk, and business impact.

+ Demonstrated ability to lead complex initiatives and drive results across multiple teams without direct reporting authority.

+ Proven ability to challenge existing processes and assumptions constructively and recommend alternative approaches supported by data and business rationale.

+ Strong executive communication skills with the 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 w...