Director, Medicaid Program Integrity - Remote

UnitedHealth Group•Tampa, FL

8d•$134,600 - $230,800•Remote

About The Position

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together. The Medicaid Program Integrity Leader is responsible for developing, implementing, and overseeing Optum’s Medicaid program integrity strategies to assist State Agencies compliance with federal and state Medicaid regulations while preventing, detecting, and addressing fraud, waste, and abuse (FWA). This leader drives operational excellence through data analytics, audits, product insight, and collaboration with internal and external stakeholders. The role balances regulatory compliance, financial stewardship, and member/provider experience to safeguard Medicaid program resources. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

Requirements

5+ years of healthcare, Medicaid, compliance, audit, investigations, or program integrity experience
5+ years of leadership experience managing teams and complex programs
5+ years of experience with fraud, waste, and abuse investigations and audit programs
2+ years of experience with Medicaid managed care regulations, CMS guidance, and program integrity requirements
2+ years of experience in data analytics and reporting capabilities
Excellent communication, executive presentation, and stakeholder management skills
Ability to travel up to 25%25

Nice To Haves

Certified Fraud Examiner (CFE), Certified Compliance & Ethics Professional (CCEP), Certified Internal Auditor (CIA), or similar certification
Experience with managed care organizations (MCOs), state Medicaid agencies, or healthcare payers
Knowledge of advanced analytics, predictive modeling, and AI-enabled fraud detection

Responsibilities

Develop and execute the organization's Medicaid Program Integrity strategy
Establish goals, KPIs, and performance metrics aligned with organizational objectives
Lead program integrity operations across pre-payment, post-payment, and support development of new business operations
Serve as a subject matter expert on Medicaid integrity requirements and emerging regulatory guidance
Ensure compliance with CMS, state Medicaid agencies, Office of Inspector General (OIG), and contractual requirements
Oversee preparation for audits, investigations, and regulatory reviews
Interpret federal and state regulations and translate them into operational policies and procedures
Maintain effective controls to support compliance and risk mitigation
Present findings, risks, and recommendations to executive leadership and governing committees
Leverage advanced analytics to identify billing anomalies, emerging fraud schemes, and utilization trends
Establish predictive and retrospective monitoring programs
Utilize data-driven approaches to prioritize investigations and maximize recoveries
Monitor program integrity performance through dashboards and executive reporting
Manage program integrity budgets and resources
Identify opportunities for cost avoidance, recoveries, and operational efficiencies
Quantify savings and return on investment for program integrity initiatives
Report financial outcomes to executive leadership
Lead multidisciplinary teams including data analysts, developers, business analysts
Foster a culture of accountability, collaboration, and continuous improvement
Develop succession plans and talent management strategies
Mentor leaders and staff to strengthen organizational capabilities