Program Integrity Contract Lead

Humana

. Work directly with Program Integrity leadership, the Compliance Officer and the Compliance Committee .

Posted 10/8/2026full-timeRemote • United StatesSenior💰 $94,900 - $130,500 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Program Integrity and Payment Integrity, with a strong focus on compliance, process improvement, and project management. Proficient in analyzing data, developing operational strategies, and implementing corrective actions to ensure adherence to contractual obligations and regulatory requirements.

Highest-signal resume keywords

Program Integrity ExperienceProject Management ExperienceLean Six Sigma MethodologiesHealthcare Compliance CertificationData Analysis and Root Cause Analysis

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Process ImprovementContract ManagementData AnalysisRoot Cause AnalysisWorkflow DesignClaims AdjudicationOperational Strategy DevelopmentPerformance MonitoringBusiness Process OptimizationImplementation Planning

Soft Skills

Excellent Communication SkillsResults-Driven MindsetHigh-Level Problem-SolvingAnalytical ThinkingAbility to Prioritize Initiatives

Tools & Technologies

Microsoft Office SuiteExcelPowerPointWordHealthcare-Related Applications

Certifications & Qualifications

Registered Nurse/Bachelor of Science in Nursing (RN/BSN)Certified Professional Coder (CPC)Certified Coding Specialist (CCS)Certified Clinical Documentation Specialist (CCDS)Certification in Healthcare Compliance (CHC)Health Care Anti-Fraud Associate (HCAFA)Accredited Health Care Fraud Investigator (AHFI)Certified Fraud Examiner (CFE)Juris Doctorate (JD)

Industry Keywords

Healthcare ComplianceGovernment ProgramsVAMedicareTRICAREContractual ObligationsService Level AgreementsKey Performance IndicatorsOperational CommitmentsPHI/HIPAA Compliance

About the role

Key responsibilities & impact

Work directly with Program Integrity leadership, the Compliance Officer and the Compliance Committee
Analyze and evaluate existing business processes and develop sustainable, repeatable and measurable improvements
Participate in and influence departmental and cross-functional strategy discussions
Recommend changes to maintain compliance with contractual obligations and regulatory requirements
Provide consultative support, internal briefings, training and participation in integrated care planning
Identify, develop and implement corrective actions with stakeholders
Perform root cause analyses and escalate significant concerns to leadership
Recommend functional strategies to address risks and gaps
Prepare and maintain Contract Data Requirements List (CDRL) reports
Manage the Program Integrity library, including letters, job aids and process flow documentation
Review associate documentation and tools
Analyze data findings and brief the team on key results and recommendations
Support data and technology teams in developing business and financial models
Translate contract requirements into business processes, workflows, controls, procedures and operational requirements
Develop implementation workplans, milestones, dependencies, risks and readiness criteria
Identify operational gaps and recommend process changes
Support development of standard operating procedures, desk-level procedures, workflows, job aids and training materials
Establish and maintain a contract monitoring framework
Monitor contract performance, service level agreements, key performance indicators, deliverables, milestones and operational commitments
Apply Lean, Six Sigma, root cause analysis and other process improvement methodologies
Conduct routine reviews to keep operational processes aligned with contractual obligations

Requirements

What you’ll need

5 or more years of Program Integrity and/or Payment Integrity experience
2 or more years of project management experience, ideally implementing large contracts
Must have one of: Registered Nurse/Bachelor of Science in Nursing (RN/BSN), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS), Certification in Healthcare Compliance (CHC), Health Care Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or Juris Doctorate (JD)
Current experience understanding claims adjudication, systems and reporting
Knowledge of healthcare-related applications and technology
Ability to manage and prioritize multiple initiatives with minimal guidance
Excellent communication and presentation skills, including communicating technical details to senior and executive leadership
Results-driven mindset and ability to achieve established goals
Experience researching and analyzing data to determine root cause
Experience reading and interpreting contracts, policies and operations manuals
High-level problem-solving and analytical experience
Proficiency in Microsoft Office Suite, Excel, PowerPoint and Word
U.S. citizenship required
Must successfully receive approval for government security clearance via National Background Investigation Services (NBIS)
Candidates currently living in Puerto Rico cannot be hired for this government contract
Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information
Home internet service with at least 25 Mbps download and 10 Mbps upload
Preferred: BA in Business, Healthcare Administration or Operations Management
Preferred: Lean Six Sigma and/or Project Management experience/certificate
Preferred: Knowledge and experience with government programs including VA, Medicare and/or TRICARE
Preferred: Previous program, technical implementation and/or initiative leadership experience
Preferred: Workflow design and business process optimization experience
Ability to learn a complex processing system

Benefits

Comp & perks

Bonus incentive plan based upon company and/or individual performance
Medical, dental and vision benefits
401(k) retirement savings plan
Paid time off
Company and personal holidays
Paid parental and caregiver leave
Short-term and long-term disability
Life insurance
Remote work arrangement
Occasional travel to Humana offices for training or meetings