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The Payment Integrity Professional 2 leverages claims data, vendor platforms, and analytic tools to identify trends, perform root cause analysis, and develop mitigation strategies that support accurate payment outcomes. This role collaborates with internal stakeholders and external code edit vendors to support pre and post implementation code editing functions. The position contributes directly to cost reduction and improved payment accuracy through data driven insights and operational execution.

Where you Come In 

The Payment Integrity Professional 2 leverages claims data, vendor platforms, and analytic tools to identify trends, perform root cause analysis, and develop mitigation strategies that support accurate payment outcomes. This role collaborates with internal stakeholders and external code edit vendors to support pre and post implementation code editing functions. The position contributes directly to cost reduction and improved payment accuracy through data driven insights and operational execution.

Responsibilities

• Analyze medical claims data to identify trends, anomalies, and performance patterns related to code editing and payment accuracy

• Conduct root‑cause analysis on incorrect payment outcomes and develop actionable mitigation plans

• Support the review, testing, implementation, and maintenance of code edits, using data to validate expected outcomes

• Partner with internal stakeholders and external vendors to translate analytic findings into operational improvements

• Investigate and resolve code edit stakeholder inquiries through data research, issue analysis, and evidence‑based recommendations

• Monitor key performance metrics, identify operational risks, and proactively recommend improvements

• Drive process optimization and contribute to successful day‑to‑day operations

• Document findings, maintain reports, and communicate results to technical and non‑technical audiences

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
 

Required Qualifications – What it takes to Succeed 

• Strong analytical skills with the ability to interpret data and identify trends

• Experience conducting root‑cause analysis and developing mitigation or corrective action plans

• Ability to manage multiple priorities and shift tasks quickly based on urgency

• Working knowledge of Microsoft Word, SharePoint, and Excel

• Comfortable making decisions in a dynamic, fast‑changing environment

• Advanced problem‑solving skills, including critical thinking and collaboration

• Ability to work independently and in a team with minimal supervision

• High attention to detail and accuracy

• Strong written and verbal communication skills

• Ability to work in a fast‑paced environment

• Commitment to confidentiality, ethical practice, and professional integrity

Preferred Qualifications

• Experience using CAS

• Experience with code edit tools such as:

  • Rialtic Provider Inquiries Tool

  • ClaimsXten Web UI

  • Cotiviti What If Tool (WIT)

  • Optum CES

  • Cotiviti Claims Inquiry Tool (CIT)

  • Nucleus

  • KnowledgeSource

• Experience analyzing medical claims data and interpreting payment outcomes

• Experience with Humana code edit processes

• Experience working with internal stakeholders and external vendors

• Familiarity with PowerPoint and OneNote

• Experience with THOR rule creation and/or maintenance

• Experience leading projects or process‑improvement initiatives

• Prior experience in Claims Administration and Payment Integrity (CAPI/CCM)

Additional Information - How we Value You
•    Benefits starting day 1 of employment 
•    Competitive 401k match  
•    Generous Paid Time Off accrual  
•    Tuition Reimbursement 
•    Parent Leave 
 

Work at Home Requirements

•            To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

·             At minimum, a download speed of 25 Mbps and an upload speed of 10 M