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The Senior Payment Integrity Professional is responsible for overseeing the MD Prep processes within the Payment Integrity team, including direct supervision of Nurse Staff Augmentation associates. This role serves as the primary point of contact for clarification questions from the Level 2 vendor, with a focus on DRG CL, Readmission, and Short Stay audits. The position requires managing the daily assignment of dispute inventory to Medical Directors, as well as distributing all modified disputes and PDX resequencing reviews to the coding team. Additionally, the Senior Payment Integrity Professional prepares and distributes MD inventory reports twice weekly to support ongoing audit accuracy and compliance.

In this role, the Senior Payment Integrity Professional will utilize technology and data mining to analyze business needs and define requirements to ensure compliance within the Medical Director Disputes Preparation space. The ability to help deliver solutions that enhance business processes, operations, and strategies is essential. This position will collaborate with stakeholders at all levels to drive business initiatives, improve performance, and ensure that business requirements are accurately translated and actionable.

Where you Come In 

As the Senior Payment Integrity Professional, you will oversee the MD Prep processes, directly supervise Nurse Staff Augmentation associates, and serve as the primary contact for clarification on DRG CL, Readmission, and Short Stay audits. You will manage daily dispute inventory assignments, coordinate with Medical Directors and coding teams, and prepare regular reports to maintain audit accuracy and compliance. By leveraging technology and data analysis, you will help define requirements, ensure compliance, and deliver solutions that enhance business processes and operations. Your collaboration with stakeholders at all levels will be key to driving initiatives, improving performance, and ensuring business needs are effectively addressed.

Key Responsibilities:

• Oversee MD Prep processes, providing direct supervision to EXL Nurse Staff Augmentation associates.
• Serve as the main point of contact for Level 2 vendor clarification questions related to DRG CL, Readmission, and Short Stay audits.
• Manage daily assignment of dispute inventory to Medical Directors and coordinate the distribution of modified disputes, including PDX resequencing reviews to the coding team.
• Prepare and distribute MD inventory reports twice weekly to ensure ongoing audit accuracy and compliance.
• Assist Medical Directors with system and process inquiries to support workflow efficiency.
• Oversee specialized inventory requiring onshore management, including Medicaid claims that need dedicated handling to ensure compliance with organizational standards and operational requirements.
• Oversee weekly production reporting and contribute to monthly metric reporting for Medicaid State Contracts, dispute inventory, and mitigation tracking.
• Utilize technology and data mining to analyze business needs, define requirements, and ensure compliance within the Medical Director Disputes Preparation space.
• Collaborate with stakeholders at all levels to drive business initiatives, improve performance, and translate business requirements into actionable solutions.
• Participate in projects involving moderately complex to complex issues, requiring thorough analysis and attention to detail

What Humana Offers 
We are fortunate to offer a remote opportunity for this job.  Our Fortune 100 Company values associate engagement & your well-being.  We also provide excellent professional development & continued education.  
 

Use your skills to make an impact
 

WORK STYLE: Remote/Work at Home. While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
WORK HOURS: Typical business hours are Monday-Friday, 8 hours/day and 5 days/week. Associates are expected to start each day between 6AM-9AM EST.

Some flexibility might be possible depending on business needs.

Required Qualifications – What it takes to Succeed 

• Active Registered Nurse (RN) license

• Experience in payment integrity, medical disputes, or a related healthcare compliance role, including experience with DRG CL, Readmission, and Short Stay audits

• Ability to collaborate with internal and external stakeholders to oversee processes, manage inventory, and ensure timely responses to questions and concerns

• Experience and familiarity with Medicaid

• Experience usin