Enterprise risk management in health coverage operations: Integrating premium billing controls-first in analytics framework for eligibility-to-invoice integrity

This research paper focuses on operationalizing Enterprise Risk Management (ERM) in health coverage premium billing to address the Governance-Execution Gap in high-growth enterprises. Although ERM is often perceived as a top-level strategic process, this paper proposes a Practical ERM-Control Architecture that connects risk identification and materiality thresholds directly to the monthly billing cycle. Using the NIST CSF 2.0 Govern function, the framework enables organizations to shift from periodic, retrospective audits to continuous monitoring (NIST, 2024). The study presents a systems approach to matching strategic risks (capital leakage and regulatory non-compliance) with automated technical controls. Key elements include a KPI Library to monitor error density and control coverage, and an Audit-Ready Evidence Pack Template for efficient compliance reporting. A residual risk model incorporating control effectiveness is introduced to quantify risk after mitigation. Using a case-based approach within a resource-constrained organization, the paper illustrates how embedding risk thresholds into the billing data pipeline increases reporting reliability and organizational resilience. The resulting blueprint offers a scalable implementation template for governance teams seeking to attain financial integrity and defensible transparency in complex regulatory environments.