Risk Management Lead

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About the role

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 opera

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