VP, Program Integrity

Job Summary :

The Vice President, Program Integrity is responsible for developing a holistic approach to Program Integrity as a key member of the Chief Legal Officer (CLO) team, responsible for driving profitable growth of the business through the use of technology, including data and analytics and intelligent automation, to drive transformation of current processes and create opportunities to eliminate manual tasks, allowing employees to focus on strategic initiatives. Responsible for mitigating risk through development of FWA strategies and execution of these strategies in alignment with assurance functions.

Essential Functions :

• Oversight of the organization responsible for the overall Program Integrity Program including payment recoveries and inappropriate payment avoidance
• Development of FWA strategies to mitigate FWA risk
• Accountability of Program Integrity performance communication to The Risk Committee and Compliance Committees as well as state Regulators
• Drive QAI (Quality and Affordability Initiatives) forecasting, execution and new Ideation to achieve corporate commitments
• Develop technology strategies to drive efficiency and effective of FWA and auditing capabilities
• Develop key metrics and tracking mechanisms to measure interventions and overall department performance
• Direct operational oversight of claims edits, reimbursement policy, clinical program (complex chart audits, provider education, and prepayment review) and the Special Investigations Unit
• Drive new initiative development, execution, and assessment, working closely with Health Care Analytics to develop best-in-industry predictive analytics, optimize build versus buy strategies, and identify opportunities for fraud, waste and abuse review
• Accountability to all market, segment and division leaders as well as state / federal authorities to deliver cost-of-care savings in a compliant and collaborative manner
• Collaboration with external stakeholders including state and federal agencies, law enforcement, trade organizations and others to influence policy, share findings and best practices as required and / or as appropriate
• Works collaboratively with Internal Audit, Compliance, and Enterprise Risk to collectively identify, prevent, address and correct Compliance and Program Integrity risks
• Identify, interpret and / or develop applicable laws, regulations, policies, and procedures to effectively and efficiently manage program operations
• Understand, prepare for, influence and effectively and efficiently implement new and emerging legislative and policy changes
• Perform any other job duties as requested

Education and Experience :

Competencies, Knowledge and Skills :

Licensure and Certification :

Working Conditions :

Compensation Range :

$150,000 - $300,000. CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type : Salary

Competencies :

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.

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