Job Summary:

The Manager, Program Integrity is responsible for managing Program Integrity requirements to include allegation intake, report analysis, triage, investigation, correction and reporting of fraud, waste and abuse

Essential Functions:

• Responsible for deposition, testifying in court in support of CareSource and Attorney General legal actions
• Manage all efforts of your investigative team focusing on thorough but timely investigations, highest impact prioritization, root cause identification, state and federal law enforcement collaboration, evidence development and investigative actions
• Drive and encourage innovative approaches to increase department effectiveness and efficiency
• Ensure quantitative and qualitative measures are used to meet performance objectives
• Develops and maintains key business contacts for investigative and SIU management purposes
• Ensure employees meet all state and federal contract requirements and follow department work processes
• Lead the Investigative team through investigative resolution including corrective action plans, terminations, Fair Hearings, recoveries, negotiations, mediation, and litigation
• Mentor employees on effective and through investigative case presentation
• Mentor direct reports including, coaching, development, performance feedback, disciplinary issues, annual performance evaluations and bonus review
• Lead and promote Employee Engagement
• Drive fraud identification through information sharing efforts, OIG Work Plan, Fraud Task Force participation and seminars
• Drive internal process and procedure changes by working with cross departmental teams to resolve identified internal system gaps that may present a FWA or financial risk to CareSource
• Take a leadership role in state and federal regulatory audits
• Proactively manage investigative team growth to meet new business requirements
• Take a leadership role in state and federal program integrity operations and fraud organizations such as NHCAA, HFPP, and ACFE
• Speak at national conferences on investigative efforts and fraud trends.
• Develop and maintain an in-depth knowledge of the company’s business and regulatory environments
• Works closely with leadership to establish, communicate, and perpetuate the corporate vision, ensuring appropriate communication to all stakeholders
• Recognize and proactively manage operational dependencies and risks
• Maintains a framework of standards and best practice methodologies that are repeatable and evidence based
• Participate in strategic planning and implement action plans
• Perform any other jobs, as requested

Education and Experience:

• Bachelor of Science/Arts Degree in Criminal Justice, Medical/Health Care Field or related industry or equivalent years of relevant work experience is required
• Minimum of six to eight (6-8) years of investigative or health care experience is required
• Extensive experience in health care, legal, auditing, claims and/or investigative services is required
• Leadership/supervisory experience preferred

Competencies, Knowledge and Skills:

• Demonstrated leadership qualities
• Support the development of effective working relationships with business partners
• Solid understanding of claims processing preferred
• Knows and uphold the provisions of the Corporate Compliance Plan
• Intermediate to advanced proficiency level of computer skills, including Microsoft Outlook, Word, Excel, Access, and Power Point
• Advanced troubleshooting and problem-solving capabilities
• Effective communication and interaction skills
• Ability to formally present to a wide audience internally and at national conferences
• Ability to lead a team and achieve performance metrics
• Highest levels of ethics, integrity and professionalism
• Significant knowledge of government program compliance requirements – Medicare, Medicaid, Affordable Care Act (ACA), etc. preferred
• Significant knowledge of medical insurance and/or state regulatory requirements

Licensure and Certification:

• Certified Fraud Examiner (CFE), Certifications through America’s Health Insurance Plans (AHIP), Healthcare Anti-Fraud Association (HCAFA) and/or Managed Healthcare Professional (MHP), Accredited Health Care Fraud Investigator (AHFI), and/or Certified Professional Coder (CPC) are preferred

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

• Fostering a Collaborative Workplace Culture

• 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 environment of belonging that welcomes and supports individuals of all backgrounds.