Program Integrity Lead

This is a fully remote position, open to applicants in United States.

📋 Description

• Act as the workstream lead for Program Integrity, overseeing audit, policy, process, and systems-related initiatives.

• Direct Medicaid program integrity efforts, focusing on the prevention of fraud, waste, and abuse; provider oversight; compliance monitoring; risk assessment; recovery efforts; and coordination of external audits.

• Spearhead the establishment and stabilization of Program Integrity unit functions, which encompass foundational processes, operating rhythms, documentation, roles, decision points, and quality controls.

• Create a practical framework and rigor for Program Integrity operations, including repeatable workflows, reporting routines, escalation pathways, audit processes, corrective action tracking, and performance monitoring.

• Evaluate and audit Medicaid medical, dental, behavioral health, and pharmacy claims to ensure accuracy, legality, reasonableness, and compliance with Medicaid policies, regulations, billing requirements, and claims data.

• Interpret and implement Medicaid policy, federal and state requirements, and pertinent code of federal regulations to facilitate compliant program operations.

• Set and monitor program integrity objectives, key performance indicators (KPIs), corrective action plans, and reporting processes.

• Examine claims data, audit outcomes, program integrity reports, recovery information, and associated documentation to pinpoint risks, trends, findings, and opportunities for enhancement.

• Develop or refine policies, procedures, requirements, guidance, recommendations, training materials, and related program integrity documentation.

• Collaborate with MQD leadership and staff to promote the adoption of new Program Integrity processes, tools, expectations, and operational methodologies.

• Create training, guidance, job aids, and transition materials to support MQD staff in the operation and sustainability of Program Integrity processes over time.

• Facilitate knowledge transfer and planning for handoff so that Program Integrity responsibilities, documentation, tools, and operational practices can transition to MQD ownership when appropriate.

• Coordinate priorities, assignments, action items, risks, blockers, dependencies, and follow-up actions among stakeholders, BerryDunn team members, vendor partners, and project leadership.

• Lead or co-lead workstream meetings, workgroups, planning sessions, and internal alignment discussions to ensure timely decisions, clear communication, and consistent follow-up.

• Maintain precise workstream information in Jira, including tasks, action items, blockers, milestones, status notes, due dates, dependencies, priorities, and reporting updates.

• Assist in weekly and monthly project reporting, closeout materials, leadership updates, and client-facing status communications.

• Review workstream documents, meeting notes, deliverables, recommendations, and client-facing materials for accuracy, consistency, quality, and alignment with project standards.

• Utilize SharePoint/KnowledgeLink for organizing, maintaining, and versioning project documentation in accordance with document management expectations.

• Promptly escalate risks, blockers, decisions, and support needs through the appropriate workstream and project management channels.

⛳️ Requirements

• Exceptional leadership, communication, facilitation, organization, and attention to detail.

• Understanding of Medicaid program integrity, fraud, waste, and abuse prevention, provider oversight, claims review, audit support, compliance monitoring, or similar public sector healthcare operations.

• Familiarity with quality assurance/control procedures, corrective action tracking, and proactive problem-solving.

• Proven ability to work effectively in a team environment and coordinate across various stakeholders, including clients, vendors, project leadership, and internal teams.

• Experience utilizing Jira or similar project management tools to monitor action items, status, ownership, deadlines, risks, blockers, dependencies, and deliverables.

• Proficiency in coordinating recurring meetings, documenting follow-up items, maintaining workstream alignment, and facilitating escalation pathways.

• Strong experience with Microsoft applications and artificial intelligence tools.

• Previous consulting experience in a national or regional consulting firm, experience collaborating with or within a state Medicaid agency, and/or experience supporting Medicaid program integrity, audit, compliance, or claims operations.

• At least three (3) years of experience within the last five (5) years in a comparable Medicaid program integrity, compliance, audit, policy, operations, project management, program management, or consulting role.

• Bachelor’s Degree (BA/BS)—four years of applicable experience may substitute for the degree.

• Preference for experience supporting healthcare, government, public sector, or Medicaid initiatives.

• Experience managing complex projects involving multiple stakeholders, vendors, workstreams, risks, issues, and deliverables.

• Experience in establishing, stabilizing, training on, or transitioning new operational units, programs, processes, or business functions.

🏝️ Benefits

• Access to benefits that exceed expectations to support physical, mental, career, social, and financial well-being.