Senior Director Program Integrity and Special Investigations Unit, Geisinger Health Plan

Geisinger is a healthcare organization focused on patient care and community well-being. The Senior Director of Program Integrity and Special Investigations Unit is responsible for the strategic direction and oversight of anti-fraud, waste, and abuse program processes, ensuring compliance with regulatory requirements and managing the SIU and PI teams.

Responsibilities:

• Provides leadership and strategic direction of Special Investigations and Program Integrity units spanning all lines of business
• Ensures compliance with all regulators on anti-fraud and program integrity regulations
• Presents to executive leadership the Privacy, Compliance and Program Integrity committee to report and communicate areas of non-compliance, risk, financial savings and potential fraud, waste or abuse
• Responsible for all PI & SI vendor relationships, including but not limited to, negotiating of contracts, adherence to key terms and ensuring contractual compliance
• Leads teams through providing guidance, training, and counseling
• Prepares and conducts performance appraisals to ensure team is high functioning and meeting both self and enterprise goals
• Monitors workflow and production within the departments and prioritizes work accordingly
• Coordinates interview process conducts interviews and initiates candidate selection
• Partner with internal stakeholders to support product strategy and sales efforts with PI data
• Collaborate with internal departments and maintain a dotted-line relationship with PI functions outside the direct organizational structure, including, but not limited to, Operations
• Oversee the configuration, testing and maintenance of the SI and PI software, including upgrades, new release implementation, to ensure proper system set-up and operations for all activity
• Oversee all external and internal Fraud, Waste and Abuse and Program Integrity audits
• Responsible for Key Performance Indicators including claim edit and claim audit savings, dollars at risk, overpayment recoveries, referrals, as well as department return on Investment
• Develops and executes a multi-year PI strategy aligned with financial goals set by the enterprise
• Manages budget and financial performance for PI and SI

Requirements:

• Master's Degree- (Required)
• Minimum of 5 years-Managerial/Supervisory (Required)
• Minimum of 10 years-Health Insurance/Managed Care (Required)
• Bachelor's Degree-Business Administration/Healthcare Management (Preferred)