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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

#LI-RA1

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.

 

$104,000 - $143,000 per year

 

This 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.

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.

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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.