Remote Risk Management Lead — Audit & Compliance

Humana Inc; Kentucky; Hybrid; USD 104,000 - 143,000; Full time

Job summary

Humana Inc. seeks a Claims Risk Management Lead to oversee investigations of alleged claim payment errors, support audits, and ensure compliance with contractual and operational requirements for VA CCN.

The role reports to the Director of Claims Risk Management and guides high-dollar claims review and remediation efforts. You will train staff, translate contract requirements into controls, develop implementation plans, and collaborate with internal teams and subcontractors to address audit

Qualifications

• 5+ years in healthcare claims operations, claims audit, payment integrity, risk management, or related healthcare environment.
• 2+ years 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.
• Proficiency in Microsoft Office, including Excel, Word, and PowerPoint.

Responsibilities

• Lead research, investigation, and documentation of alleged claim payment errors for audits.
• Train and mentor staff in preparing audit packages and rebuttal responses.
• Document root causes and monitor corrective actions.
• Collaborate with internal partners and subcontractors on findings and resolution.
• Provide guidance for review of high-dollar claims.
• Translate contractual requirements into audit controls and workflows.
• Develop implementation work plans with milestones and risks.
• Identify gaps and recommend process improvements to meet obligations.
• Support SOPs, desk-level procedures, workflows, and training materials.
• Work with cross-functional teams to monitor systemic errors and risks.
• Contribute to risk management and audit dashboards.
• Use analytics to summarize findings and recommend actions.
• Support special projects directed by leadership.
• Use your skills to make an impact.

Skills

Healthcare claims

Audit & compliance

Risk management

Contract interpretation

Project leadership

Data analysis

Communication skills

Microsoft Office

Education

Bachelor’s degree in business, healthcare administration, finance, or a related field

Job description

Humana Inc. seeks a Claims Risk Management Lead to oversee investigations of alleged claim payment errors, support audits, and ensure compliance with contractual and operational requirements for VA CCN.

The role reports to the Director of Claims Risk Management and guides high-dollar claims review and remediation efforts. You will train staff, translate contract requirements into controls, develop implementation plans, and collaborate with internal teams and subcontractors to address audit