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The Risk Management Lead acts as a consultant to the Risk Adjustment team leaders, as programs and initiatives are executed upon. Leveraging risk management and compliance frameworks, they will identify and analyze potential risks and sources of loss to evaluate business processes and drive improvements aimed at minimizing risk. The Lead will focus on Project Management and is responsible for oversight of the Risk Adjustment Operations processes. The Risk Management Lead works on problems of diverse scope and complexity ranging from moderate to substantial.The Risk Management Lead estimates the potential financial consequences of an occurring loss. Develops and implements controls and cost-effective approaches to minimize the organization's risks. Assesses and communicates information regarding business risks with functions across the organization. Advises executives to develop functional strategies (often segment specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks and works under minimal supervision. Uses independent judgment requiring analysis of variable factors and determining the best course of action. In addition, this role provides consultative services to drive efficient, effective, and compliant risk adjustment processes.
This Risk Adjustment Risk Management lead position will be responsible for providing risk management and compliance oversight of Risk Adjustment Operations, including the areas of Encounter Submissions, Record Retrieval and Coding, Financial Operations and Vendor Management within Humana's Healthcare Quality Reporting and Improvement department. Responsibilities of the role will include the following:
- Evaluating processes and procedures to ensure adequate controls are included
- Monitor compliance requirements specific to risk adjustment operations
- Conduct audits to ensure controls and processes are being executed with minimal risk
- Conduct risk assessments, as necessary, to identify current gaps in processes
- Collaborate with business area associates to develop remediation plans to close gaps
- Collaborate with business area teams and compliance partners to consult on initiatives and drive process excellence
- Develop annual work plan for responsible areas
- Understand and assist in financial control assessment and work collaboratively with internal and external auditors
- Evaluate Risk Adjustment Operations monthly progress against goals
- Track and report on project status
Use your skills to make an impact
Required Qualifications
- Bachelor's degree
- 2 or more years of project leadership experience
- 1+ year of audit, compliance, and/or risk experience
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
- Strong relationship building skills
- Ability to take the initiative
- Ability to manage multiple initiatives at a time and ensure progress is moving forward
Preferred Qualifications
- Applicable Bachelor's degree - Accounting, Finance, Business, Auditing, Actuarial
- Certified Internal Auditor, CPA or CPC strongly preferred
- Risk Adjustment knowledge
- Experience with PowerBI for advanced data visualization and reporting and other experience in data analytics
- Auditing experience
- Familiarity with CMS Reimbursement models and claims/encounter submission processes
- Data analysis and dashboarding experience
- People leadership experience
Additional Information
Location: Nationwide (U.S.); however, candidates located in the Eastern Standard Time (EST) Zone are strongly preferred to support alignment with team schedules and collaboration.
Work-At-Home Requirements:
- WAH requirements: Must have the ability to provide a high-speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
- A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
- Satellite and Wireless Internet service is NOT allowed for this role.
- 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 for you pertaining to your relevant skills and experience at a time that is best for your schedule.
If you are selected, you will receive correspondence inviting you to participate in a HireVue assessment. You will have a set of questions and you will provide responses to each question. You should anticipate this to take about 15 - 20 minutes. Your answers will be reviewed, and you will subsequently be informed if you will be moving forward to next round.
Scheduled Weekly Hours
40Pay 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.$104,000 - $143,000 per yearThis 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: 12-30-2025
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.
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