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:

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):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.