Job Description:

• Identify net-new Payment Integrity and Data Mining opportunities through industry trends, reimbursement and policy changes, provider billing patterns, claims data, and portfolio performance
• Monitor Medicare, Medicaid, and Commercial reimbursement trends
• Research payment leakage and develop hypotheses for new audit concepts
• Maintain awareness of external Payment Integrity practices, technology, and analytical approaches
• Translate opportunities into defined audit concepts and testable business hypotheses
• Define concept intent, claims population, expected payment behavior, policy rationale, preliminary logic, and financial opportunity
• Partner with analytical, clinical, coding, policy, technology, and operational teams to test and validate concepts
• Evaluate results and recommend advancing, modifying, scaling, or discontinuing concepts
• Drive concepts from idea through validation and implementation
• Influence cross-functional partners without direct authority
• Resolve barriers and establish ownership, milestones, dependencies, and success measures
• Communicate recommendations to leaders and stakeholders
• Evaluate existing concepts to improve accuracy, financial performance, uphold rates, efficiency, and provider experience
• Identify and remediate unnecessary rework, disputes, appeals, overturns, and administrative expense
• Recommend refining, automating, moving upstream, consolidating, or retiring concepts
• Advise Payment Integrity leadership on emerging opportunities, portfolio performance, and industry developments
• Provide executive-level recommendations supported by claims analysis, financial impact, operational considerations, and risk assessment
• Lead complex initiatives across analytical, operational, clinical, technology, and business stakeholders
• Mentor others involved in opportunity identification, concept development, testing, and optimization
• Work remotely from home with occasional travel to Humana offices for training or meetings
• Align work schedule with Eastern Standard Time business hours as needed

Requirements:

• 8+ years of healthcare, Payment Integrity, claims, reimbursement, audit, healthcare analytics, payment policy, or related experience
• Demonstrated experience interpreting healthcare claims and understanding reimbursement methodologies, payment policies, coding, contracts, or benefit requirements
• 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 and ambiguous business problems
• Strong analytical and critical-thinking skills
• Ability to evaluate financial opportunity, operational feasibility, risk, and business impact
• Ability to lead complex initiatives across multiple teams without direct reporting authority
• Ability to challenge existing processes and assumptions constructively
• Strong executive communication skills
• Ability to manage multiple high-priority initiatives and measurable outcomes
• Advanced proficiency with Excel, PowerPoint, and other analysis and communication tools
• Sound independent judgment and decision-making
• Commitment to confidentiality and appropriate handling of healthcare and business information
• Preferred: deep experience in Payment Integrity, Data Mining, claims audit, medical cost management, Special Investigations, Fraud, Waste & Abuse, revenue recovery, or healthcare payment analytics
• Preferred: experience developing net-new healthcare claims audit or Payment Integrity concepts through implementation
• Preferred: experience with Prepay and Postpay Payment Integrity strategies
• Preferred: understanding of Medicare, Medicaid, and/or Commercial reimbursement methodologies
• Preferred: knowledge of CMS reimbursement methodologies, coding guidance, healthcare payment policies, provider billing practices, and emerging industry trends
• Preferred: experience using large claims datasets or analytical tools
• Preferred: experience evaluating concept performance using savings, yield, accuracy, uphold/overturn rates, disputes, appeals, recoverability, and operational cost
• Preferred: experience developing business cases or financial opportunity estimates
• Preferred: experience taking concepts through ideation, analysis, testing, validation, implementation, and optimization
• Preferred: experience influencing senior leaders and cross-functional stakeholders
• Preferred: experience supporting medical cost savings or cost-of-care initiatives
• Preferred: familiarity with Payment Integrity technology platforms, claims systems, data mining solutions, and/or advanced analytics
• Experience with claims modernization, automation, machine learning, or AI-enabled Payment Integrity solutions is a plus
• Project management, Lean, Six Sigma, healthcare coding, auditing, clinical, or related professional certification is preferred
• Minimum download speed of 25 Mbps and upload speed of 10 Mbps
• Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information

Benefits:

• Bonus incentive plan based on company and/or individual performance
• Medical benefits
• Dental benefits
• Vision benefits
• 401(k) retirement savings plan
• Paid time off
• Company holidays
• Personal holidays
• Paid parental leave
• Paid caregiver leave
• Short-term disability
• Long-term disability
• Life insurance
• Internet expense payment for associates working from home in California, Illinois, Montana, or South Dakota
• Telephone equipment provided for Home or Hybrid Home/Office associates
• Remote work at home
• Flexible scheduling aligned to the associate's home time zone and EST as needed