Responsible for the strategic direction, planning, oversight, and operation of the Special Investigations (“SI”) and Program Integrity (“PI”) teams.
Develops and directs the prevention, detection and investigation of anti-fraud, waste and abuse (FWA) program processes and oversight and coordination of all program integrity activities.
Ensures all regulatory requirements are met including the completion of annual fraud plans and reports.
Acts as a point of contact for collaboration with local, state and federal law enforcement and regulatory partners.
Provides executive management with reimbursement or recovery recommendations based on PI team’s review of claims for appropriate coding, billed statistics, policies, industry standards and compliance with contractual, state, and federal regulation.
Responsible for the management of the SIU and Program Integrity teams, their contracts and strategies and meeting the financial saving goals set by the enterprise.

Master's Degree
(Required)
Bachelor's Degree-Business Administration/Healthcare Management (Preferred)
Minimum of 5 years-Managerial/Supervisory (Required)
Minimum of 10 years-Health Insurance/Managed Care (Required)
Skills: Computer Literacy, Healthcare Industry, Leadership, Manages Conflict And Crisis, Working Independently.

We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.
Encourages an atmosphere of collaboration, cooperation and collegiality.

Senior Director, Program Integrity and Special Investigations

Key skills