Risk Management Lead

Humana; United States; Remote; USD 120,000 - 150,000; Full time

Job summary

Humana is seeking a Claims Risk Management Lead to drive compliance, audit readiness, and operational performance for VA CCN. The role leads investigations of alleged claim payment errors, supports external audits, and guides remediation actions with cross-functional partners.

Responsibilities include developing controls from contract requirements, mentoring staff, and translating findings into actionable operational improvements for high-dollar claims.

Qualifications

• 5+ years of experience in healthcare claims operations, claims audit, payment integrity, risk management, compliance, or a related healthcare environment
• Strong knowledge of 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 written and verbal communication skills, including the ability to prepare reports, rebuttals, and leadership summaries
• Proficiency in Microsoft Office, including Excel, Word, and PowerPoint

Responsibilities

• Lead and coordinate research, investigation, and documentation of alleged claim payment errors for audits
• Train and mentor staff in preparing audit packages and rebuttals
• Document root causes and support corrective action plans
• Collaborate with internal partners and subcontractors on audit findings and resolutions
• Provide guidance for review of high-dollar claims and escalation
• Interpret contractual requirements into audit controls and workflows
• Develop and support implementation workplans with milestones and risks
• Identify gaps and recommend process improvements to meet obligations
• Assist in developing SOPs, desk-level procedures, workflows, and training materials
• Partner cross-functionally to monitor systemic processing errors and risks
• Contribute to audit reporting dashboards for leadership review
• Summarize key findings and present actionable recommendations
• Support special projects and leadership initiatives

Skills

Analytical skills

Communication skills

Organizational skills

Problem-solving

Team leadership

Education

Bachelor's degree in business, healthcare administration, finance, or related

Tools

Microsoft Office (Excel, Word, PowerPoint)

Job description

Become a part of our caring community

The Claims Risk Management Lead reports to the Director of Claims Risk Management and leads activities supporting claims compliance, audit readiness, and operational performance for VA CCN. This role oversees the investigation and resolution of alleged claim payment errors, supports quarterly external audits and oversight of random audits, and collaborates with internal and external partners to ensure compliance with contractual and operational requirements. The Lead also provides guidance on high-dollar claims, supports root cause analysis and corrective actions, and helps translate contract requirements into operational processes, controls, and monitoring activities.

This position is created specifically to assist with Humana's efforts to secure and, if awarded, transition into a new business opportunity. Please note that continued employment in this role is expressly contingent upon Humana's receipt of the business opportunity and a satisfactory transition into the work. In the event Humana does not pursue the opportunity or determines that a timely and satisfactory transition cannot be achieved, employment may be subject to termination.

As a Risk Management Lead, you will:

• Lead and coordinate research, investigation, and documentation of alleged claim payment errors in support of quarterly external audits and random audit oversight.
• Train, mentor, and support staff in the preparation of audit packages, written rebuttal responses and audit-related documentation in accordance with applicable contract requirements, policies, and procedures.
• Document root causes for confirmed errors, support corrective action planning, and monitor remediation efforts to reduce repeat issues and strengthen operational performance.
• Collaborate with internal business partners, delegated entities, and claims processing subcontractors regarding audit findings, disputes, operational impacts, and resolution activities.
• Provide guidance and subject matter expertise for the review of high-dollar claims, ensuring appropriate investigation, escalation, and follow-up.
• Interpret and translate contractual requirements into audit controls, procedures, workflows, and monitoring activities to support compliant claims administration.
• Develop and support implementation workplans, including milestones, dependencies, risks, and readiness criteria for projects.
• Identify gaps and recommend process improvements necessary to meet contractual obligations and improve audit readiness.
• Support the development and maintenance of standard operating procedures, desk-level procedures, workflows, job aids, and training materials.
• Partner cross-functionally to identify, monitor, and address systemic claims processing errors and related compliance risks.
• Contribute to the development and enhancement of risk management and audit reporting dashboards for leadership review.
• Utilize strong analytics, technical, and communication skills to summarize key findings and present actionable recommendations to various levels of leadership.
• Support special projects and initiatives as directed by leadership.

Use your skills to make an impact

REQUIRED QUALIFICATIONS

• 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

PREFERRED QUALIFICATIONS

• Bachelor's degree in business, healthcare administration, finance, or a related field
• Experience supporting VA CCN or other government healthcare contracts
• Experience working with delegated entities, subcontractors, or external business partners in support of claims oversight or audit activities

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 m