Senior Payment Integrity Professional (RN/Nursing License required)

**Become a part of our caring community and help us put health first** 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 using the following systems: CAS, CRM, PAREO + Comprehensive knowledge of Microsoft Office Programs Word, PowerPoint, and Excel + Proven organizational skills and keen attention to detail with demonstrated ability to lead process/project initiatives + Can work independently, problem solve, and determine appropriate courses of action + Responsible for maintaining effective communication, supporting accurate workflow management, and addressing inquiries promptly to uphold compliance and operational standards. + Excellent communication skills, with the ability to collaborate across teams and with external vendors. **Preferred Qualifications** + Experience in Disputes and with MOAT/EFR system + 2 or more years of direct or indirect/formal or informal leadership experience + Knowledge of Microsoft Office Programs Access and Project + Experience in a fast paced, metric driven operational setting **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 Mbps is recommended; wireless, wired cable or DSL connection is suggested · Satellite, cellular and microwave connection can be used only if approved by leadership · Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. · Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job. · Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information **Interview Format** As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. 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. $71,100 - $97,800 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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 07-23-2025 **About us** Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large. ​ **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. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our