Senior Claims Risk & Audit 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

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.