Director, Program Integrity

Job Summary:

The Director, Program Integrity is responsible for scoping, planning, prioritizing, and managing all Program Integrity’s actions and functions.

Essential Functions:

• Formulates strategies and implements approach to identify and address FWA risks to members and the Company
• Drives advocacy and awareness efforts for healthcare/Medicaid/Medicare FWA issues with state and federal legislators
• Monitors emerging FWA legislative and policy issues at state and federal levels with the goal of proactive organizational response to opportunities and issues
• Collaborates with state and national trade associations on key FWA investigations, policy issues and advocacy objectives
• Mitigates company risks identified in the course of investigations such as policies and procedures, claim system edits, and other deficiencies, etc.
• Prepares, monitors, and executes the department budget; monitors and approves department expenses
• Chairs the Investigations Committee where investigative results and recommended corrective actions are presented to Executive Management to obtain their endorsement
• Reports investigative actions to the Compliance Committee
• Hires, trains, develops and appraises Special Investigation staff ensuring a strong, competent and talented team of high integrity professionals
• Presents FWA schemes and training internally and at national conferences
• Conducts on-site audits of medical professionals, business partners and contracted entities
• Collaborates with law enforcement, regulatory agencies, Fraud Task Force members, medical boards, etc. to facilitate FWA identification, prevention, and investigation
• Provides testimony as needed in any FWA matters involving litigation both criminally and civilly
• Prepares timely reports regarding identified FWA to all appropriate state and federal agencies
• Participates in departmental and corporate strategic planning, initiative prioritization and recommended action plans as they relate to Program Integrity
• Required to know and uphold the provisions of the Corporate Compliance Plan
• Perform any other job related instructions, as requested 

Education and Experience:

• Bachelor’s degree or equivalent work experience in Law Enforcement, Accounting, or a Medical discipline with significant experience in health insurance investigations is required
• Minimum seven (7) years healthcare investigation experience required
• Minimum five (5) years healthcare management experience required

Competencies, Knowledge and Skills:

• Advanced level experience in Microsoft Office products
• Data analysis and trending skills
• Executive leadership experience and skills
• Knowledge of medical insurance and/or state regulatory requirements desirable.
• High level investigative experience
• Excellent written and oral communication skills
• Ability to communicate effectively with executive management and business community
• Proven results-oriented leadership
• Attention to detail
• Critical listening and thinking skills
• Training/teaching experience
• Negotiation skills/experience
• Customer service orientation
• Communication skills
• Strategic management skills
• Negotiation skills/experience
• Decision making/problem solving skills
• Advanced knowledge of healthcare billing and coding

Licensure and Certification:

• NICB, IASIU, ACFE, or NHCAA certificates or training in healthcare fraud and abuse investigations, preferred but not required

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

$110,800.00 - $193,800.00

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Salary

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

 

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