Overview

Our client is seeking a Director of Program Integrity to lead and oversee operational functions related to claims editing, fraud prevention, and payment accuracy. This leader ensures compliance, operational excellence, and the integrity of Medicaid and Managed Care program operations.

The Director will be responsible for managing teams, optimizing workflows, ensuring regulatory adherence, and developing strategies to prevent improper payments.

Qualifications – Required

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  Bachelor’s degree or higher
  (Eight (8) years of experience in Texas Medicaid or Medicaid Managed Care may be considered in lieu of a degree.)

  
  


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  2+ years of Managed Care experience

  
  


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  1+ year of Medicaid experience

  
  


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  1+ year of experience in at least one of the following:

  
  
  
  
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    ICD-10

    
    
  
  
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    Medical Coding

    
    
  
  
  
  


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  Valid certification in at least one of the following:

  
  
  
  
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    Lean Six Sigma

    
    
  
  
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    Project Management Professional (PMP)

    
    
  
  
  
  

Additional Required Experience

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  Five (5) years of management experience

  
  


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  2 years of experience within a Managed Care health plan or state agency

  
  


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  5 years of Texas Medicaid, Managed Care Health Plan, or State agency experience

  
  


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  Knowledge of ICD-10 and CPT/HCPCS coding guidelines and terminology

  
  

Strongly Preferred Experience

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  Eight (8) years of experience in Payment Integrity Audit and Recovery, including:

  
  
  
  
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    Data mining

    
    
  
  
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    Clinical medical record review

    
    
  
  
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    Bill audit recovery

    
    
  
  
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    Fraud, waste, and abuse prevention

    
    
  
  
  
  


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  Prior experience specifically in Health Plan (payer-side) payment integrity,

  
  

Key Responsibilities

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  Evaluate and improve job designs, work processes, and workflows to maximize departmental effectiveness and efficiency.

  
  


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  Stay current on industry trends, policy changes, and regulatory requirements through continuous learning and professional development.

  
  


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  Maintain expert knowledge of relevant rules, regulations, policies, and laws impacting Medicaid and Managed Care operations.

  
  


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  Develop and oversee annual departmental budgets to ensure adequate resources for achieving operational goals.

  
  


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  Establish, implement, and monitor annual departmental goals, objectives, and strategic plans.

  
  


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  Recruit, train, mentor, schedule, supervise, and evaluate staff to maintain high performance and engagement.

  
  

Schedule & Onsite Requirements

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  Onsite presence required at least 6 days per month

  
  


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  Standard schedule aligns with organizational leadership expectations (details may vary by client)