AVP, Program Integrity

Job Summary:

The Associate Vice President, Program Integrity Operations is responsible for driving overall compliance, process and data Program Integrity and as well as Internal Controls and risk management performance results across all areas of Program Integrity, ensuring effective execution of enterprise Program Integrity programs to achieve enterprise Program Integrity goals.

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
• Execute on Program Integrity strategy for multiple markets, working collaboratively with market and enterprise senior leaders, to achieve accreditation, state and other regulatory Program Integrity performance standards and enterprise Program Integrity goals
• Chairs the Investigations Committee where investigative results and recommended corrective actions are presented to Executive Management to obtain their endorsement
• Collects Data and generates reports of Program Integrity actions to the Compliance Committee and Board
• 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
• Oversee Program Integrity Committee performance ensuring necessary participation, effectiveness and alignment of Committee activities and outputs with regulatory standards
• Develop and implement standardized Program Integrity improvement initiatives, programs, tools and innovations to improve market performance and delivery of high-Program Integrity care and services across the Enterprise
• Monitor effectiveness of Program Integrity programs and interventions, utilizing Program Integrity tools and continuous Program Integrity improvement framework
• Monitor and report out on key Program Integrity and performance indicators and associated interventions
• Manage relationships with state departments and Program Integrity organizations as needed
• Drive a culture of continuous Program Integrity improvement across the organization
• Lead between Market/Product teams and Enterprise activities to ensure timely and accurate responsiveness and resolution to any systems, regulatory, or compliance issues related to Program Integrity
• Create data quality process and controls with monitoring and oversight processes

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
• Master’s degree in healthcare or business is preferred
• Minimum seven (7) years healthcare investigation experience required
• Minimum of five (5) years of leadership and management experience in managed care setting is required
• Minimum of five (5) years of Program Integrity improvement in the healthcare or managed care industry is required

Competencies, Knowledge and Skills:

• Advanced proficiency level with Microsoft Office
• Data analysis and trending skills (SQL experience preferred)
• Executive leadership experience and skills
• Knowledge of full range of product requirements from regulatory, operations, and compliance
• Critical listening and systematic thinking skills
• Ability to attract, manage and develop team members through inspirational leadership
• Ability to maintain confidentiality and act in the company’s best interest
• Strong oral, written, and interpersonal communication skills
• Ability to act with diplomacy and sensitivity to cultural diversity
• Responsive to a changing environment
• Health Plan Financial & Administration Management Acumen
• Strategic management skills
• Conflict resolution skills
• Planning, problem identification and resolution skills

Licensure and Certification:

• NICB, IASIU, ACFE, or NHCAA certificates or training in healthcare fraud and abuse investigations are preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• This role may require up to 20% travel based on the needs of the department

Compensation range $150,000-$300,000. 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

• Energize and Inspire the Organization

• 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.