{"id":3836979,"url":"https://alion.io/job/humana-payment-integrity-lead-strategy-audit-optimization","title":"Payment Integrity Lead - Strategy & Audit Optimization","company":{"id":2742,"name":"Humana","domain":"humana.com","url":"https://alion.io/company/humana","size_band":"5000+","is_staffing_agency":false,"employer_type":"direct","is_intermediary":false,"listed_via":null,"ats_vendor":"Workday","truth_index":{"grade":"A","score":95,"open_postings":51,"ghost_share":0.059,"stale_share":0.078,"repost_share":0.314,"time_to_fill_p50_days":14,"computed_at":"2026-11-10T06:52:35Z"}},"role":"Communications","role_family":"Communications","seniority":"lead","employment_type":"full_time","work_mode":"remote","remote_scope":"stated_countries","remote_scope_basis":"board_field","remote_working_hours":{"label":"EST","utc_offset_min":-5,"utc_offset_max":-5},"hiring_geo_confidence":"structured","locations":["United States"],"countries":["US"],"hiring_countries":["US"],"hiring_countries_total":1,"salary":{"min":94900,"max":130500,"currency":"USD","period":"year","gross":null,"usd_annual":130500},"salary_estimate":null,"experience_years_min":null,"visa_sponsorship":false,"relocation_package":false,"has_equity":false,"technologies":[{"name":"HIPAA","optional":true},{"name":"Machine Learning","optional":true}],"status":"live","first_seen_at":"2026-11-05T21:21:44Z","employer_posted_date":"2026-11-05","last_verified_at":"2026-11-10T05:08:53Z","board_verified":true,"closed_at":null,"days_open":4,"trust":{"level":"ok","repost_count":null,"flags":[],"days_open":4},"description":"Become a part of our caring community\nThe 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.\nThis 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.\nThe 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.\nSuccess 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.\nThis 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.\nKey Responsibilities\nNew Opportunity & Trend Identification\nProactively 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.\nMonitor Medicare, Medicaid, and Commercial reimbursement trends to identify changes that may create new Payment Integrity opportunities.\nIndependently research potential payment leakage and develop hypotheses for new audit concepts, including opportunities that do not fit existing processes.\nMaintain awareness of external Payment Integrity practices, technology, and emerging analytical approaches that could strengthen Humana's strategy.\n\nConcept Development & Testing\nTranslate identified opportunities into clearly defined audit concepts and testable business hypotheses.\nDefine concept intent, claims population, expected payment behavior, policy rationale, preliminary logic, and expected financial opportunity.\nPartner with analytical, clinical, coding, policy, technology, and operational teams to test and validate new concepts.\nEvaluate results and recommend whether to advance, modify, scale, or discontinue concepts, balancing speed with validation so concepts are operationally sound and defensible.\nOperationalization & Influence\nDrive promising concepts from idea through validation and implementation, creating accountability and momentum across teams.\nInfluence partners across Payment Integrity and the broader organization without direct authority over required resources.\nResolve barriers to high-value concepts and establish clear ownership, milestones, dependencies, and success measures.\nCommunicate recommendations clearly to leaders and stakeholders, including when they challenge existing processes or assumptions.\nConcept & Audit Optimization\nEvaluate existing concepts for opportunities to improve accuracy, financial performance, uphold rates, efficiency, and provider experience.\nIdentify concepts generating unnecessary rework, disputes, appeals, overturns, or administrative expense and determine remediation.\nRecommend opportunities to refine, automate, move upstream, consolidate, or retire concepts based on performance data, keeping resources focused on high-value, sustainable interventions.\nStrategy & Leadership\nServe as a strategic thought partner to Payment Integrity leadership on emerging opportunities, portfolio performance, and industry developments.\nProvide concise, executive-level recommendations supported by claims analysis, financial impact, operational considerations, and risk assessment.\nLead complex initiatives spanning analytical, operational, clinical, technology, and business stakeholders.\nHelp 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.\nUse your skills to make an impact\nWORK STYLE: Remote, work at home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.\nWORK 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.\nRequired Qualifications\n8+ years of healthcare, Payment Integrity, claims, reimbursement, audit, healthcare analytics, payment policy, or related experience.\nDemonstrated experience interpreting healthcare claims and understanding how reimbursement methodologies, payment policies, coding, contracts, or benefit requirements affect claim payment.\nStrong knowledge of the healthcare payer environment and the end-to-end claims lifecycle.\nDemonstrated ability to identify opportunities from data, industry developments, claims patterns, or business trends and translate findings into actionable recommendations.\nExperience developing, testing, implementing, or optimizing healthcare payment, audit, claims, or analytical concepts.\nAbility to independently navigate complex and ambiguous business problems where the solution or path forward is not predefined.\nStrong analytical and critical-thinking skills with demonstrated ability to evaluate financial opportunity, operational feasibility, risk, and business impact.\nDemonstrated ability to lead complex initiatives and drive results across multiple teams without direct reporting authority.\nProven ability to challenge existing processes and assumptions constructively and recommend alternative approaches supported by data and business rationale.\nStrong executive communication skills with the ability to translate detailed claims, analytical, or reimbursement findings into concise business recommendations.\nAbility to manage multiple high-priority initiatives while maintaining accountability for milestones and measurable outcomes.\nAdvanced proficiency with Excel, PowerPoint, and other tools used to analyze information and communicate complex findings.\nDemonstrated sound independent judgment and decision-making on complex business issues.\nStrong commitment to confidentiality and appropriate handling of healthcare and business information.\nPreferred Qualifications\nDeep experience in Payment Integrity, Data Mining, claims audit, medical cost management, Special Investigations, Fraud, Waste & Abuse, revenue recovery, or healthcare payment analytics.\nExperience identifying and developing net-new healthcare claims audit or Payment Integrity concepts from initial hypothesis through implementation.\nExperience with both Prepay and Postpay Payment Integrity strategies.\nStrong understanding of Medicare, Medicaid, and/or Commercial reimbursement methodologies.\nKnowledge of CMS reimbursement methodologies, coding guidance, healthcare payment policies, provider billing practices, and emerging industry trends.\nExperience using large claims datasets or analytical tools to identify patterns, outliers, payment leakage, or potential concept opportunities.\nExperience evaluating concept performance using measures such as savings, yield, accuracy, uphold/overturn rates, provider disputes, appeals, recoverability, and operational cost.\nExperience developing business cases or financial opportunity estimates for new Payment Integrity initiatives.\nDemonstrated experience taking concepts through ideation, analysis, testing, validation, implementation, and ongoing optimization.\nExperience influencing senior leaders and cross-functional stakeholders on complex or potentially controversial recommendations.\nExperience supporting organizational medical cost savings or cost-of-care initiatives.\nFamiliarity with Payment Integrity technology platforms, claims systems, data mining solutions, and/or advanced analytics.\nExperience with healthcare claims modernization, automation, machine learning, or AI-enabled Payment Integrity solutions is a plus.\nProject management, Lean, Six Sigma, healthcare coding, auditing, clinical, or related professional certification is preferred.\nAdditional Information\nWork at Home Requirements\nAt minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested\nSatellite, cellular and microwave connection can be used only if approved by leadership\nAssociates 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.\nHumana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.\nWork from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information\nInterview Format\nAs 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.\nIf 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.\nIf 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.\nWork 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.\nScheduled Weekly Hours\n40Pay Range\nThe 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. 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