Program Integrity Contract Lead

Become a part of our caring community

The Program Integrity (PI) Contract Lead is an important member of the leadership team and works directly with Program Integrity Leadership, the Compliance Officer, and the Compliance Committee. This position requires a strong understanding of the VA Community Care Network (CCN) program, including, but not limited to, federal health care program requirements, Executive Order 12549, Federal Acquisition Regulation (FAR) Part 3, the Federal False Claims Act, and applicable state and federal laws governing program integrity and compliance.

The PI Contract Lead analyzes and evaluates the effectiveness of existing business processes and develops sustainable, repeatable, and measurable process improvements. You will participate in and influence departmental and cross-functional strategy discussions, recommending changes needed to maintain compliance with contractual obligations and regulatory requirements. You will address issues of varied scope and complexity, ranging from moderate to significant.

The PI Contract Lead works collaboratively with key stakeholders to provide consultative support, internal briefings, training, and participation in integrated care planning, as needed. You will partner with stakeholders to identify, develop, and implement corrective actions. Responsibilities include performing root cause analyses, escalating significant concerns to leadership, and recommending functional strategies to address identified risks or gaps. Decisions may involve resource allocation, operational approach, tactical execution, and department-level initiatives.

Administrative responsibilities include, but are not limited to, preparing and maintaining Contract Data Requirements List (CDRL) reports; managing the Program Integrity library, including letters, job aids, and process flow documentation; reviewing associate documentation and tools; analyzing data findings; and briefing the team on key results and recommendations. The PI Contract Lead also provides support to data and technology teams in the development of business and financial models.

KEY ACCOUNTABILITIES

35% Translate contract requirements into business processes, workflows, controls, procedures, and operational requirements. Develop implementation workplans, milestones, dependencies, risks and readiness criteria for projects

25% Identify operational gaps and recommend process changes necessary to meet contractual requirements. Support development of standard operating procedures, desk level procedures, workflows, job aids and training materials.

15% Establish and maintain an ongoing contract monitoring framework to ensure continued compliance with contractual requirements. Monitor contract performance, service level agreements, key performance indicators, deliverables, milestones, and operational commitments.

15% Apply Lean, Six Sigma, root cause analysis and other process improvement methodologies to improve operational and contract performance.

10% Conduct routine reviews of contract requirements to ensure operational processes remain aligned with current contractual obligations.

This role description in no way states or implies that the key accountabilities above are the only ones being performed by the individual(s) with this role description. The individual(s) may be called upon and required to follow other instructions or perform other duties and tasks requested by his or her supervisor, consistent with the purpose of the position, department and/or company objectives.

Use your skills to make an impact

Required Qualifications

• 5 or more years of Program Integrity and/or Payment Integrity experience
• 2 or more years of project management (Ideally in implementing large contracts) experience
• Must have ONE of the following ant-fraud degrees, designations, and/or certifications:

-Registered Nurse/Bachelor of Science in Nursing (RN/BSN)

-Certified Profession 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)

• Current experience with understanding claims adjudication, systems and reporting
• Knowledge in healthcare related applications and technology
• Ability to manage and prioritize multiple initiatives with minimal guidance
• Excellent communication and presentation skills to include the ability to communicate and present technical details to senior and executive level leadership
• Results-driven mindset with the ability to achieve established individual and organizational goals
• Experienced in researching and analyzing data to determine root cause within areas of opportunity
• Experience reading and interpreting documents such as contracts, policy and operations manuals
• High level problem-solving and analytical experience
• Proficiency in Microsoft office suite Excel, PowerPoint and Word
• Our Department of Defense Contract requires U.S. citizenship for this position
• Successfully receive approval for government security clearance (Via National Background Investigation Services NBIS)
• HGB is not authorized to do work in Puerto Rico per our government contract. We are not able to hire candidates that are currently living in Puerto Rico

Preferred Qualifications

• BA in Business, HealthCare Administration or Operations Management
• Lean Six Sigma and/or Project Management Experience/Certificate
• Knowledge and experience working with Government programs to include VA, Medicare and/or TRICARE
• Previous experience managing or leading programs, technical implementations and/or initiatives
• Prior experience with Workflow design and Business Process Optimization
• Ability to learn a complex processing system

Additional Information

Work Style: Remote

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: 10-16-2026

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.

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.