Payment Integrity Lead – Strategy & Audit Optimization

Humana

. Identify net-new Payment Integrity and Data Mining opportunities through industry trends, reimbursement and policy changes, provider billing patterns, claims data, and portfolio performance .

Posted 11/5/2026full-timeRemote • United StatesSenior💰 $94,900 - $130,500 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates extensive experience in Payment Integrity, claims analysis, and reimbursement methodologies, with a strong ability to translate data insights into actionable audit concepts. Proven leadership in managing complex initiatives across cross-functional teams while maintaining a focus on financial performance and operational feasibility.

Highest-signal resume keywords

Payment Integrity ExpertiseHealthcare Claims AnalysisReimbursement MethodologiesAnalytical Concept DevelopmentExecutive Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Healthcare AnalyticsClaims Data InterpretationAudit Concept DevelopmentData MiningFinancial Opportunity EvaluationOperational Feasibility AssessmentRisk AssessmentProcess OptimizationClaims Lifecycle UnderstandingHealthcare Payment Policies

Soft Skills

Analytical ThinkingCritical ThinkingProblem SolvingInfluencing Without AuthorityMentoring

Tools & Technologies

ExcelPowerPointClaims SystemsData Mining SolutionsAdvanced Analytics Tools

Certifications & Qualifications

Project Management CertificationLean CertificationSix Sigma CertificationHealthcare Coding CertificationAuditing Certification

Industry Keywords

MedicareMedicaidCommercial ReimbursementFraud, Waste & AbuseRevenue RecoveryHealthcare Payer EnvironmentClaims ModernizationMachine LearningAI-Enabled SolutionsPayment Integrity Technology Platforms

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

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