The Program Integrity Manager is an individual contributor role responsible for fraud, waste and abuse and specific research leading to best practice policy implementation and vendor/subcontractor monitoring to drive problem/process resolution for the District of Columbia Medicaid health plan
- This position must reside within in the District of Columbia proper
- You will work in the office as needed and have the flexibility to work from home the rest of the time
- Works to ensure that internal processes are executed, especially related to intersegment responsibilities, for fraud, waste, and abuse (FWA) vendors’ instances of health care FWA by medical profession or insured member
- Acts as FWA subject matter expert for Federal and local FWA regulations and subsequent regulatory policy and process implementation
- Keeping apprised of current, proposed, and new federal and state regulations / guidelines
- Ensures that changes in requirements are included in education and carried out by required audiences
- Serves as health plan FWA trainer
- Coordinates and supports implementation of FWA training and educational programs with the appropriate business areas and vendors
- As necessary, gather and analyze all information and documents related to a FWA investigation
Acts as health plan FWA vendor liaison, i.e., conducts reviews on policies to make sure they are compliant; ensures that vendor processes are executed appropriately; that timelines are met per regulatory fulfillment; sets boundaries for vendors so that accountabilities are clear
- Serves as regulatory FWA liaison to the regulatory entities and internally to key FWA organizational partners, including participation in meetings with regulators
- Develops and maintains fraud-related policies, e.g., documents the education and hand-offs for the health plan from functional teams as required to meet contractual obligations
- Oversees and ensures all required FWA regulatory reporting meets regulatory expectations
- Ensures procedures are established to support timely communication and education regarding the fraud program
- Ensures that procedures are in place to review and report possible violations in accordance with the reporting requirements as outlined in the FWA Plan
- Reviews vendors to make sure that all aspects of FWA are managed and policies are developed where gaps are identified
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in
