Risk Management Lead

Humana

. Lead and coordinate research, investigation, and documentation of alleged claim payment errors for quarterly external audits and random audit oversight .

Posted 10/7/2026full-timeRemote • Kentucky • United StatesSenior💰 $104,000 - $143,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare claims operations, audit processes, and compliance management, with a strong focus on developing corrective action plans and process improvements. Proficient in analyzing claims data and translating contractual requirements into effective operational controls.

Highest-signal resume keywords

Healthcare Claims OperationsClaims AuditRisk ManagementReimbursement MethodologiesCorrective Action Planning

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ProcessingRoot Cause AnalysisPayment IntegrityAudit Findings ResolutionProcess ImprovementContract InterpretationAnalytical SkillsMicrosoft ExcelMicrosoft WordMicrosoft PowerPoint

Soft Skills

Organizational SkillsProblem-Solving SkillsWritten CommunicationVerbal CommunicationMentoring

Certifications & Qualifications

Government Security Clearance (NBIS)

Industry Keywords

Healthcare AdministrationCompliance ReviewsVA CCNSubcontractor ManagementAudit Reporting

About the role

Key responsibilities & impact

Lead and coordinate research, investigation, and documentation of alleged claim payment errors for quarterly external audits and random audit oversight
Train, mentor, and support staff in preparing audit packages, written rebuttal responses, and audit-related documentation
Document root causes for confirmed errors, support corrective action planning, and monitor remediation efforts
Collaborate with internal business partners, delegated entities, and claims processing subcontractors on audit findings, disputes, operational impacts, and resolutions
Provide subject matter expertise for reviewing high-dollar claims, including investigation, escalation, and follow-up
Interpret contractual requirements and translate them into audit controls, procedures, workflows, and monitoring activities
Develop and support implementation workplans with milestones, dependencies, risks, and readiness criteria
Identify gaps and recommend process improvements to meet contractual obligations and improve audit readiness
Develop and maintain standard operating procedures, desk-level procedures, workflows, job aids, and training materials
Identify, monitor, and address systemic claims processing errors and related compliance risks
Contribute to risk management and audit reporting dashboards for leadership review
Summarize key findings and present actionable recommendations to leadership
Support special projects and initiatives as directed by leadership

Requirements

What you’ll need

Must successfully receive interim approval for government security clearance (NBIS – National Background Investigation Services)
5+ years of experience in healthcare claims operations, claims audit, payment integrity, risk management, compliance, or a related healthcare environment
Strong knowledge of and experience applying reimbursement methodologies for Institutional and Professional claims
2+ years of experience leading projects, processes, or teams
Experience researching and resolving claim payment errors, audit findings, and operational issues
Experience interpreting contract requirements, policies, and regulatory guidelines and translating them into operational processes, controls, and monitoring activities
Experience supporting external audits, internal audits, or compliance reviews
Knowledge of claims processing, payment integrity, root cause analysis, and corrective action methodologies
Experience developing and implementing corrective action plans, remediation activities, and process improvements
Strong analytical, organizational, and problem-solving skills
Strong written and verbal communication skills, including the ability to prepare reports, rebuttals, and leadership summaries
Proficiency in Microsoft Office, including Excel, Word, and PowerPoint
Bachelor's degree in business, healthcare administration, finance, or a related field (preferred)
Experience supporting VA CCN or other government healthcare contracts (preferred)
Experience working with delegated entities, subcontractors, or external business partners in support of claims oversight or audit activities (preferred)
Home internet service with at least 25 Mbps download and 10 Mbps upload
Ability to work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information

Benefits

Comp & perks

Bonus incentive plan based on company and/or individual performance
Medical, dental, and 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
Dedicated work-from-home space supporting PHI/HIPAA privacy
Remote work arrangement
Occasional travel to Humana offices for training or meetings may be required