Payment Integrity Lead

The Payment Integrity Lead uses technology and data mining to detect anomalies in data and identify overpayments of claims. This role contributes to investigations of fraud, waste, and financial recovery.

The Payment Integrity Lead - Strategy & Audit Optimization is a strategic leadership role that identifies, evaluates, and advances new Payment Integrity opportunities to drive sustainable 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.
• Maintain awareness of external Payment Integrity practices, technology, and emerging analytical approaches.

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.

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.

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.

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.

WORK STYLE:

• Remote, work at home. 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 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 with Excel, PowerPoint, and other tools used to analyze information and communicate complex findings.
• Demonstrated sound independent judgment and decision-making on complex business issues.
• Strong commitment to confidentiality and appropriate handling of healthcare and business information.