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Director of Program Integrity
Director of Program IntegrityTalentPlug LLC • Dallas, TX, US
Director of Program Integrity

Director of Program Integrity

TalentPlug LLC • Dallas, TX, US
[job_card.variable_days_ago]
[job_preview.job_type]
  • [job_card.full_time]
[job_card.job_description]

Summary :

  • Our client is seeking a Director of Program Integrity to lead and oversee operations focused on claims editing, fraud prevention, and payment accuracy.
  • This role is essential for ensuring operational excellence and adherence to regulations.

Key Responsibilities :

  • Identifies and analyses the design of jobs, work processes, work flows, etc. for the area and implements appropriate changes to improve effectiveness, productivity, and efficiency.
  • Stays abreast of the latest developments, advancements, and trends in the field by attending seminars / workshops and reading professional journals.
  • Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area.
  • Develops and monitors annual budgets that ensure the department has the necessary funds to carry out the goals and objectives.
  • Develops, implements, monitors, and revises annual goals and objectives for the department.
  • Selects, trains, schedules, motivates, supervises, and evaluates employees. Schedule and Shift Details
  • Will have to be onsite at least SIX DAYS a month.

    • Required :

  • Bachelor's degree or higher
  • Managed Care (2+ years)
  • Medicaid (1+ years)
  • 1+ years of experience in ANY of the following :

    • ICD10

    Medical Coding

  • ANY of the following valid licenses / certifications :

    • Lean Six Sigma

    Project Management Professional (PMP)

    Experience seeking :

  • Five (5) years of management experience - Required.
  • Eight (8) years of experience in Payment Integrity Audit and Recovery with knowledge of audit strategies such as Data Mining, Clinical Medical Record Review, and Bill Audit Recovery / Program Integrity experience - Strongly Preferred.
  • 2 years of experience in a Managed Care health plan or state agency - Required.
  • Knowledge of ICD-10 and CPT / HCPC coding guidelines and terminology - Required.
  • Eight (8) years of experience in a comparable position working in Texas Medicaid or Medicaid Managed Care may be considered in lieu of a bachelor's degree.
  • 5 Years of Texas Medicaid, Managed Care Health Plan or State agency experience - Required.
  • Please list the types of Medicaid Health Plans that your candidate is familiar with.
  • HM looking only considering candidates who actually have payment integrity, rather than revenue recovery experience.
  • Payer-focused on preventing overpayments and preventing fraud, waste, and abuse.
  • Health Plan experience, not healthcare system experience
  • Certification / Registration / Licensure Project management or Six Sigma certification - Strongly Preferred.

    • Internal notes :

  • Primarily Works Remote - Must Be On-Site 6 Days Per Month Submission Requirements
  • "By submitting your applicant to this need you are acknowledging that you have checked and have no inclination that your candidate has applied directly to this position. Any candidate that has applied directly is not eligible to be on boarded through an agency."
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