The Senior Director, Program Integrity provides strategic and operational leadership over the organization's enterprise-wide fraud, waste, and abuse (FWA) program, ensuring regulatory compliance, risk mitigation, and program effectiveness across all states. Reporting to the Vice President, Compliance, this role serves as the primary senior liaison with regulatory and law enforcement agencies, including OMIG and MFCUs, and oversees fraud detection, investigation, audit readiness, and corrective action management. The Senior Director establishes governance frameworks, drives data-informed integrity initiatives, standardizes processes across markets and health plan partners, and leads continuous improvement efforts to identify emerging risks, strengthen controls, and promote a culture of accountability and compliance.
Duties & Responsibilities:Regulatory & External Relationship Management- Map, maintain, and continuously update a comprehensive inventory of all relevant state program integrity agencies, including MFCUs and state Medicaid integrity units
- Serve as the primary point of contact with regulators, including OMIG, MFCUs, and other law enforcement and oversight entities
- Establish and maintain strong, credible relationships with regulatory partners to support collaboration, transparency, and trust
- Collaborate with Health Plans in fraud, waste and abuse investigation and referral processes.
- Oversee and standardize fraud, waste, and abuse referral processes across all states, ensuring timeliness, completeness, and regulatory compliance
- Monitor evolving regulatory expectations and ensure program alignment with federal and state requirements
Program Integrity Strategy & Governance- Design and implement an enterprise-wide program integrity framework aligned with organizational risk, regulatory expectations, and industry best practices
- Develop and maintain a centralized fraud risk register, including risk identification, scoring, mitigation strategies, and ownership
- Establish governance structures for fraud oversight, including reporting to executive leadership and compliance committees
- Catalogue and continuously update fraud prevention and detection best practices across the organization
Fraud Detection, Investigation & Oversight- Oversee fraud investigation and auditing
- Ensure effective intake, triage, investigation, and resolution of suspected fraud, waste, and abuse cases
- Provide strategic direction and oversight for complex, high-risk investigations
- Ensure proper documentation, case management, and audit readiness
- Monitor and ensure execution of corrective action plans (CAPs) resulting from investigations, audits, and regulatory findings
Analytics, Reporting & Performance Measurement- Oversee the design, implementation, and continuous enhancement of program integrity dashboards and reporting tools
- Partner with data/analytics teams to develop predictive and retrospective fraud detection methodologies
- Establish KPIs and performance metrics for fraud detection, investigation efficiency, and prevention impact
- Quantify and report cost savings and cost avoidance resulting from fraud prevention and detection initiatives
- Leverage data mining and trend analysis to identify emerging fraud schemes and risk areas
Program Development & Continuous Improvement- Lead the development and execution of fraud prevention initiatives, including pre-payment controls and policy enhancements
- Identify systemic vulnerabilities and implement proactive interventions to mitigate risk
- Drive continuous improvement through benchmarking, regulatory insights, and industry collaboration
- Support training and awareness programs related to fraud, waste, and abuse
Required Skills:- Excellent knowledge of relevant laws, regulations and industry standards
- CDPAP and Medicaid experience
- Experience managing relationships with MFCUs and state oversight agencies
- Ability to communicate complex compliance issues clearly and effectively
- Expert in FWA and ANE investigative processes
- Strong analytical, interpersonal, and organizational skills
- Proficiency in Microsoft Office technology; comfortable learning new systems and communicating system design needs
- Demonstrated competence in reviewing contracts and other legal and regulatory documents
- Strong attention to detail and process improvement
- Excellent written and oral communication skills
- Ability to negotiate with partners for prioritization and resource allocation
- Comfortable with healthy conflict
- Skilled at developing and maintaining accountability within corporations
- Demonstrated ability to build highly effective teams and manage staff
- Strong work ethic and ability to prioritize tasks in a fast-paced, dynamic environment
Qualifications:Education: - Bachelor's degree preferred; Substantial professional experience may be considered in lieu of a formal degree.
Experience:- 10+ years of relevant work experience in a compliance leadership role required
- 5+ years of leadership experience
- Experience with fraud waste and abuse prevention, detection, investigation and management in healthcare
- Experience in managing regulatory relationships and audits (both internal and external) required
- Experience with government contracts and familiarity with Medicaid
Certification: CFE or AHFI highly desirable
Working ConditionsRemote with occasional business travel
Compensation & Benefits:- 401k Retirement Plan
- Medical, Dental and Vision insurance on first day of employment
- Generous Paid Time Off
- Employee Assistance Program and more
Compensation range: $145,000 - $160,000 annually
The above is intended to describe the general contents and requirements of work being performed by people assigned to this classification. It is not intended to be construed as an exhaustive statement of all duties, responsibilities, or skills of personnel so classified
