Job Description

The Director of Program Integrity provides leadership oversight and directs the operations for the Program Integrity department and associated functions with focus on claims editing, fraud, waste, and abuse (FWA) prevention, and

payment accuracy. Accountable for supporting Community Health Plan’s commitment

to operational excellence, cost containment, and adherence to state and federal requirements.

Looking 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.

***Will have to be onsite in Dallas, TX at least SIX DAYS a month.***

Experience:

• 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.
• Knowledge of Texas Medicaid (STAR, STAR Kids/CHIP) program, National Committee for Quality
• Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.

Certification/Registration/Licensure

• Project management or Six Sigma certification - Strongly Preferred.

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