Payment Integrity Lead - Strategy & Audit Optimization

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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 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.

Preferred Qualifications

• Deep experience in Payment Integrity, Data Mining, claims audit, medical cost management, Special Investigations, Fraud, Waste & Abuse, revenue recovery, or healthcare payment analytics.
• Experience identifying and developing net-new healthcare claims audit or Payment Integrity concepts from initial hypothesis through implementation.
• Experience with both Prepay and Postpay Payment Integrity strategies.
• Strong understanding of Medicare, Medicaid, and/or Commercial reimbursement methodologies.
• Knowledge of CMS reimbursement methodologies, coding guidance, healthcare payment policies, provider billing practices, and emerging industry trends.
• Experience using large claims datasets or analytical tools to identify patterns, outliers, payment leakage, or potential concept opportunities.
• Experience evaluating concept performance using measures such as savings, yield, accuracy, uphold/overturn rates, provider disputes, appeals, recoverability, and operational cost.
• Experience developing business cases or financial opportunity estimates for new Payment Integrity initiatives.
• Demonstrated experience taking concepts through ideation, analysis, testing, validation, implementation, and ongoing optimization.
• Experience influencing senior leaders and cross-functional stakeholders on complex or potentially controversial recommendations.
• Experience supporting organizational medical cost savings or cost-of-care initiatives.
• Familiarity with Payment Integrity technology platforms, claims systems, data mining solutions, and/or advanced analytics.
• Experience with healthcare 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.
  

Additional Information

Work at Home Requirements

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

• Satellite, cellular and microwave connection can be used only if approved by leadership

• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Interview Format

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Hire Vue (formerly Modern Hire) to enhance our hiring and decision-making ability. Hire Vue (formerly Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$94,900 - $130,500 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.Application Deadline: 11-12-2026

About us

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.

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Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.