Director of Program Integrity
We are partnered with a leading Behavioral Healthcare organization who is seeking a strategic and experienced Director of Program Integrity to lead the organization's efforts in detecting, preventing, and remediating fraud, waste, and abuse (FWA) across behavioral health, direct medical care, and other healthcare services. This role is critical in ensuring compliance, operational excellence, and financial integrity through robust auditing, data analysis, and cross-functional collaboration.
Key Responsibilities
- Strategic Oversight: Lead the design and execution of the FWA program, including claims audits, data analytics, and investigations.
- Compliance & Risk Management: Ensure accurate coding, proper claims processing, and adherence to regulatory and documentation standards.
- Cross-Functional Collaboration: Serve as the primary liaison with internal departments, regulators, enforcement agencies, and health plan partners.
- Innovation & Operational Excellence: Enhance FWA detection tools, refine policies, and manage vendor relationships and reporting systems.
- Team Leadership: Mentor and manage a high-performing team, fostering a culture of accountability, collaboration, and continuous improvement.
Required Qualifications
- Bachelor's degree in healthcare, public administration, or a related field.
- 7+ years of experience in healthcare claims auditing, investigations, compliance, or program integrity.
- 3+ years of proven leadership or management experience.
- Deep knowledge of healthcare coding systems (CPT4, HCPCS, DRG, ICD-9/10, Revenue Codes).
- Strong background in overpayment recovery and fraud detection through data analysis and mining.
Preferred Skills
- Experience developing audit plans, SOPs, training materials, and workflow documentation.
- Familiarity with managed care reimbursement and contracting.
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