Job Summary:

Owns responsibility for ensuring the optimal performance of the Program Integrity division within enterprise contracts, continuously monitoring and analyzing performance metrics to identify opportunities for improving processes and procedures. Assists and supports Senior Manager - Program Integrity in operations and administration of contracts, overseeing the day-to-day activities of investigative teams and leading in targeted/strike force reviews and intelligence targeting. Communicates regularly and serves as a liaison with government agencies, regulatory bodies, and other external stakeholders to ensure transparent and compliant company programs.

Essential Functions:

Directs teams to monitor and ensure compliance with relevant laws, regulations, and organizational policies, working to prioritize and collaborate on investigations and fraud schemes.
Identifies and evaluates potential risks to program integrity and develops strategies to mitigate these risks.
Installs best of class measures to maintain and improve the quality of program activities, ensuring they meet established standards.
Formulates and implements strategies to detect and prevent fraud within programs, including establishing controls and monitoring systems.
Acts independently to assess existing processes for efficiency, effectiveness, and compliance.
Collaborates with other departments, stakeholders, and external entities to ensure a holistic approach to program integrity.
Conducts advanced investigations into potential instances of fraud, misconduct, or non-compliance; takes appropriate corrective actions.
Maintains accurate documentation of program activities and produces regular reports on program integrity metrics and compliance status.
Instructs program staff on relevant compliance and integrity matters to ensure understanding and adherence to policies.
Manages team performance through regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development.

Level of Supervision Received:
Drives work independently and escalates questions and issues, as needed

Education (can be substituted for experience):
Minimum Bachelor's Degree required

Work Experience (can be substituted for education):
8 - 11 years of experience required; 12 - 14 years preferred

Certification(s):
Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator preferred

Qlarant

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