[Hiring] Payment Integrity Lead @Humana

Role Description

The Payment Integrity Lead uses technology and data mining to detect anomalies in data and identify overpayment of claims. This role contributes to investigations of fraud waste and financial recovery, working on problems of diverse scope and complexity.

The Payment Integrity Lead - Strategy & Audit Optimization is responsible for:

• Identifying, evaluating, and advancing new Payment Integrity opportunities that drive sustainable medical cost savings.
• Serving 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, and provider behaviors.
• Developing hypotheses, assessing financial opportunity and operational feasibility, and influencing cross-functional partners.

Success in this role requires:

• Strong Payment Integrity and healthcare claims knowledge.
• Intellectual curiosity and sound business judgment.
• Ability to turn ambiguous opportunities into measurable results.

Key Responsibilities

• New Opportunity & Trend Identification:
  • Proactively identify net-new Payment Integrity and Data Mining opportunities.
  • Monitor Medicare, Medicaid, and Commercial reimbursement trends.
  • Independently research potential payment leakage and develop hypotheses for new audit concepts.
  • Maintain awareness of external Payment Integrity practices 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, and expected financial opportunity.
  • Partner with various teams to test and validate new concepts.
  • Evaluate results and recommend actions based on validation.
• Operationalization & Influence:
  • Drive promising concepts from idea through validation and implementation.
  • Influence partners across Payment Integrity and the broader organization.
  • Resolve barriers to high-value concepts and establish clear ownership and success measures.
  • Communicate recommendations clearly to leaders and stakeholders.
• Concept & Audit Optimization:
  • Evaluate existing concepts for opportunities to improve accuracy and financial performance.
  • Identify concepts generating unnecessary rework and determine remediation.
  • Recommend opportunities to refine, automate, or retire concepts based on performance data.
• Strategy & Leadership:
  • Serve as a strategic thought partner to Payment Integrity leadership.
  • Provide concise, executive-level recommendations supported by claims analysis.
  • Lead complex initiatives spanning various stakeholders.
  • Help build a culture of curiosity and continuous improvement.

Qualifications

• 8+ years of healthcare, Payment Integrity, claims, reimbursement, audit, healthcare analytics, or related experience.
• Demonstrated experience interpreting healthcare claims and understanding reimbursement methodologies.
• Strong knowledge of the healthcare payer environment and the end-to-end claims lifecycle.
• Ability to identify opportunities from data and translate findings into actionable recommendations.
• Experience developing, testing, implementing, or optimizing healthcare payment concepts.
• Strong analytical and critical-thinking skills.
• Demonstrated ability to lead complex initiatives without direct reporting authority.
• Strong executive communication skills.
• Advanced proficiency with Excel, PowerPoint, and other analytical tools.
• Strong commitment to confidentiality and appropriate handling of healthcare information.

Requirements

• Deep experience in Payment Integrity, Data Mining, claims audit, or healthcare payment analytics.
• Experience identifying and developing healthcare claims audit concepts from initial hypothesis through implementation.
• Strong understanding of Medicare, Medicaid, and/or Commercial reimbursement methodologies.
• Experience using large claims datasets to identify patterns or potential concept opportunities.
• Experience evaluating concept performance using various measures.
• Experience developing business cases for new Payment Integrity initiatives.
• Experience influencing senior leaders on complex recommendations.
• Familiarity with Payment Integrity technology platforms and advanced analytics.

Benefits

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off, including company and personal holidays.
• Paid parental and caregiver leave.
• Short-term and long-term disability.
• Life insurance and many other opportunities.

Work Style

• Remote, work at home with occasional travel to Humana's offices.
• Typical work hours are Monday-Friday, aligning with EST as needed.

Scheduled Weekly Hours

40

Pay Range

$94,900 - $130,500 per year, eligible for a bonus incentive plan.

Application Deadline

11-12-2026

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment based on various protected statuses.