The Program Integrity (PI) Contract Lead is an important member of the leadership team and works directly with Program Integrity Leadership, the Compliance Officer, and the Compliance Committee. This position requires a strong understanding of the VA Community Care Network (CCN) program, including, but not limited to, federal health care program requirements, Executive Order 12549, Federal Acquisition Regulation (FAR) Part 3, the Federal False Claims Act, and applicable state and federal laws governing program integrity and compliance.
The PI Contract Lead analyzes and evaluates the effectiveness of existing business processes and develops sustainable, repeatable, and measurable process improvements. You will participate in and influence departmental and cross-functional strategy discussions, recommending changes needed to maintain compliance with contractual obligations and regulatory requirements. You will address issues of varied scope and complexity, ranging from moderate to significant.
The PI Contract Lead works collaboratively with key stakeholders to provide consultative support, internal briefings, training, and participation in integrated care planning, as needed. You will partner with stakeholders to identify, develop, and implement corrective actions. Responsibilities include performing root cause analyses, escalating significant concerns to leadership, and recommending functional strategies to address identified risks or gaps. Decisions may involve resource allocation, operational approach, tactical execution, and department-level initiatives.
Administrative responsibilities include, but are not limited to, preparing and maintaining Contract Data Requirements List (CDRL) reports; managing the Program Integrity library, including letters, job aids, and process flow documentation; reviewing associate documentation and tools; analyzing data findings; and briefing the team on key results and recommendations. The PI Contract Lead also provides support to data and technology teams in the development of business and financial models.
35% Translate contract requirements into business processes, workflows, controls, procedures, and operational requirements. Develop implementation workplans, milestones, dependencies, risks and readiness criteria for projects
25% Identify operational gaps and recommend process changes necessary to meet contractual requirements. Support development of standard operating procedures, desk level procedures, workflows, job aids and training materials.
15% Establish and maintain an ongoing contract monitoring framework to ensure continued compliance with contractual requirements. Monitor contract performance, service level agreements, key performance indicators, deliverables, milestones, and operational commitments.
15% Apply Lean, Six Sigma, root cause analysis and other process improvement methodologies to improve operational and contract performance.
10% Conduct routine reviews of contract requirements to ensure operational processes remain aligned with current contractual obligations.
This role description in no way states or implies that the key accountabilities above are the only ones being performed by the individual(s) with this role description. The individual(s) may be called upon and required to follow other instructions or perform other duties and tasks requested by his or her supervisor, consistent with the purpose of the position, department and/or company objectives.
-Registered Nurse/Bachelor of Science in Nursing (RN/BSN)
-Certified Profession Coder (CPC)
-Certified Coding Specialist (CCS)
-Certified Clinical Documentation Specialist (CCDS)
-Certification in Healthcare Compliance (CHC)
-Health Care Anti-Fraud Associate (HCAFA)
-Accredited Health Care Fraud Investigator (AHFI)
-Certified Fraud Examiner (CFE)
-Juris Doctorate (JD)
Work Style: Remote
Work at Home Requirements: 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. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
40
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.
$94,900 - $130,500 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
Application Deadline: 10-16-2026
About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
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 will never ask, nor require a candidate to provide money for work equipment and network access during the application process. If you become aware of any instances where you as a candidate are asked to provide information and do not believe it is a legitimate request from Humana or affiliate, please contact yourcareer@humana.com to validate the request
At Humana, our cultural foundation is aligned to helping members achieve their best health by delivering personalized, simplified, whole-person healthcare experiences. Recognizing healthcare needs continue to evolve for each person, for each family and for each community, Humana continuously creates innovative solutions and resources that help people live their healthiest lives on their terms –when and where they need it. Our employees are at the heart of making this happen and that’s why we are dedicated to building an organization of dynamic talent whose experience and passion center on putting the customer first.
