Clinical Coding Director, Payment Integrity

Become a part of our caring community and help us put health first
 

The Director, Payment Integrity uses technology and data mining, detects anomalies in data to identify and collect overpayment of claims. The Director leverages technology and the clinical and coding expertise of their associates to identify potential overpayments to be substantiated via review of medical records. The Director contributes to the investigations of fraud, waste and abuse. The Director requires an in-depth understanding of how organizational capabilities interrelate across the function or segment.

The Clinical and Coding Medical Record Review Director of Payment Integrity contributes to overall cost reduction, by increasing the accuracy of provider payments in our payer systems, and by ensuring correct claims payment. The Director contributes to overall cost reduction, by increasing the accuracy of provider payments via a complex array of medical record audit programs performed by coders and clinicians. The Director oversees internal teams and stacked vendor operations conducting reviews of inpatient and outpatient services using automation, new innovative technology and expertise. The Director will make decisions related to the implementation of new/updated programs or large-scale projects. The Director will lead Operations for technical procedures and processes, and implements strategic plans, drives goals and objectives, and improves performance.

Use your skills to make an impact
 

Required Qualifications

• Bachelor's degree in business, healthcare administration, clinical, information systems, or a related field

• 5 or more years of proven management experience in a healthcare or claims related field (Ideally leading large-scale operations)

• Proven experience and ability to determine the needed approach, resources, and goals to meet business objectives and execute quickly

• Excellent communication and presentation skills to include the ability to communicate and present technical details to Senior level leadership and/or Senior Government officials

• Ability to work with project stakeholders, contracting, providers, IT, enterprise partners, clinical leaders at all levels in the organization in a collaborative, team environment

• Strong business acumen and proven experience analyzing complex metrics and making high impact data driven decisions

• Exceptional Operational experience ideally working within a large matrixed organization and multiple systems/tech stacks

• Critical thinker who can anticipate team needs and take initiative to present ideas, ask the right questions and deliver the highest quality work

• Experience with facilitating, consulting, and delivering complex concepts

• Strong computer & technology skills (e.g. Excel, Word, PowerPoint with an interest in learning and applying AI capabilities and applications and other programs required for assimilating and presenting reports)

• Strong understanding of Human Resource principles and aligning talent with key components of our business strategy to create value for all stakeholders

• Self-starter who takes initiative and ownership and anticipates future consequences and trends accurately

• Ability to apply knowledge of new technology, artificial intelligence applications and business management concepts to improve operations

• Ability to manage multiple tasks, priorities and deadlines with attention to detail

Preferred Qualifications

• Master's Degree in Business, Health Administration or related field

• Experience managing vendors

• Experience with medical record reviews

• Experience with developing or modernizing technology

• Knowledge of coding and clinical or healthcare reimbursement

• Payment Integrity industry expertise

• Ability to interpret federal regulations & contracts

Additional Information

Work At Home / Internet Information:

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.

• Satellite, cellular and microwave connection can be used only if approved by leadership.

• Employees 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 employees 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.

SSN Alert:

Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana’s secure website.

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.

 

$138,900 - $191,000 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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

Application Deadline: 03-09-2026

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.

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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.