VP, Program Integrity

Job Summary:

The Vice President, Program Integrity is responsible for developing a holistic approach to Program Integrity as a key member of the Chief Legal Officer (CLO) team, responsible for driving profitable growth of the business through the use of technology, including data and analytics and intelligent automation, to drive transformation of current processes and create opportunities to eliminate manual tasks, allowing employees to focus on strategic initiatives. Responsible for mitigating risk through development of FWA strategies and execution of these strategies in alignment with assurance functions.

Essential Functions:

• Oversight of the organization responsible for the overall Program Integrity Program including payment recoveries and inappropriate payment avoidance
• Development of FWA strategies to mitigate FWA risk
• Accountability of Program Integrity performance communication to The Risk Committee and Compliance Committees as well as state Regulators
• Drive QAI (Quality and Affordability Initiatives) forecasting, execution and new Ideation to achieve corporate commitments
• Develop technology strategies to drive efficiency and effective of FWA and auditing capabilities
• Develop key metrics and tracking mechanisms to measure interventions and overall department performance
• Direct operational oversight of claims edits, reimbursement policy, clinical program (complex chart audits, provider education, and prepayment review) and the Special Investigations Unit
• Drive new initiative development, execution, and assessment, working closely with Health Care Analytics to develop best-in-industry predictive analytics, optimize build versus buy strategies, and identify opportunities for fraud, waste and abuse review
• Accountability to all market, segment and division leaders as well as state/federal authorities to deliver cost-of-care savings in a compliant and collaborative manner
• Collaboration with external stakeholders including state and federal agencies, law enforcement, trade organizations and others to influence policy, share findings and best practices as required and/or as appropriate
• Works collaboratively with Internal Audit, Compliance, and Enterprise Risk to collectively identify, prevent, address and correct Compliance and Program Integrity risks
• Identify, interpret and/or develop applicable laws, regulations, policies, and procedures to effectively and efficiently manage program operations
• Understand, prepare for, influence and effectively and efficiently implement new and emerging legislative and policy changes
• Perform any other job duties as requested

Education and Experience:

• Bachelor of science degree in business administration, healthcare administration or related discipline or equivalent years of relevant work experience is required
• Master’s in Business Administration, Healthcare Administration and/or other related discipline is preferred
• Minimum of ten (10) years of program integrity, compliance, SIU or related experience is required
• Five (5) years Senior Leadership experience with a managed care organization or related industry is required

Competencies, Knowledge and Skills:

• Strong working knowledge of program integrity, including government program compliance, fraud, waste and abuse, laws, regulations, guidelines and professional standards
• Strong collaborative skills, working with cross-functional stakeholders and external partners
• Skilled in identifying, understanding, and adapting outstanding practices and processes to help improve performance
• Has relentlessly high standards and is results-oriented
• Demonstrates business acumen and strategic thinking, yet able to execute tactically
• Detail oriented, well organized with strong time and project management skills
• Solid leadership skills, effectively manage a high performing team, provide coaching and development
• Demonstrated ability to adjust to shifting priorities, multi-task, work under pressure and meet deadlines
• Proven ability to recognize opportunity for improvement and lead change
• Influences others individually and broadly across the organization
• Knowledge of full range of organization development interventions and change management frameworks and applications
• Pursues innovative approaches for implementing strategic solutions

Licensure and Certification:

• Certified in Health Care Compliance (CHC) is preferred
• Certified Fraud Examiner (CFE) is preferred
• Accredited Healthcare Fraud Investigator (AHFI) is preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

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

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Energize and Inspire the Organization

• Influence Others

• Pursue Personal Excellence

• Understand the Business