Payment Integrity Lead - Strategy & Audit Optimization
H
HumanaHealthcare payment integrity
Source API remote eligibility restrictions: United States, Meetings may require alignment with EST (Eastern Standard Time) business hours.Full-TimeLead
Salary$94,900 - $130,500 per year
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Job Details
- Experience
- 8+ years of healthcare, Payment Integrity, claims, reimbursement, audit, healthcare analytics, payment policy, or related experience.
- Required Skills
- Data MiningCross-functional Team LeadershipMicrosoft ExcelPowerPoint
Requirements
- Have 8+ years of experience in healthcare, Payment Integrity, claims, reimbursement, audit, healthcare analytics, payment policy, or a related area.
- Demonstrate experience interpreting healthcare claims and understanding how reimbursement methodologies, payment policies, coding, contracts, or benefit requirements affect claim payment.
- Have strong knowledge of the healthcare payer environment and end-to-end claims lifecycle.
- Demonstrate ability to identify opportunities from data, industry developments, claims patterns, or business trends and turn findings into actionable recommendations.
- Have experience developing, testing, implementing, or optimizing healthcare payment, audit, claims, or analytical concepts.
- Be able to independently navigate complex, ambiguous business problems where the solution or path forward is not predefined.
- Demonstrate analytical and critical-thinking skills to evaluate financial opportunity, operational feasibility, risk, and business impact.
- Have experience leading complex initiatives and driving results across teams without direct reporting authority.
- Communicate detailed claims, analytical, or reimbursement findings as concise business recommendations for executives.
- Manage multiple high-priority initiatives while maintaining accountability for milestones and measurable outcomes.
- Have advanced proficiency with Excel, PowerPoint, and other tools used to analyze information and communicate complex findings.
- Preferred: experience with Payment Integrity, Data Mining, claims audit, medical cost management, Medicare, Medicaid, or Commercial reimbursement; project management, Lean, Six Sigma, coding, auditing, or related professional certification.
Responsibilities
- Identify 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 for potential Payment Integrity opportunities.
- Research potential payment leakage and develop hypotheses for new audit concepts.
- Define audit concepts, including their 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 concepts.
- Evaluate test results and recommend whether to advance, modify, scale, or discontinue concepts.
- Drive promising concepts from idea through validation and implementation, establishing ownership, milestones, dependencies, and success measures.
- Evaluate existing concepts and recommend ways to improve accuracy, financial performance, efficiency, and provider experience.
- Advise Payment Integrity leaders with recommendations supported by claims analysis, financial impact, operational considerations, and risk assessment.
- Lead complex initiatives across analytical, operational, clinical, technology, and business stakeholders, and mentor others in opportunity identification and concept development.
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