Program Director - Program Integrity (Fraud, Waste & Abuse)

Blue Cross Blue Shield of Minnesota•Eagan, MN

7d•Hybrid

About The Position

The Program Director, Program Integrity is responsible for developing and leading the enterprise-wide internal and external strategy, governance, and outcomes of the organization’s Fraud, Waste, and Abuse (FWA) prevention and detection program. This leadership role drives execution across multiple stakeholder teams and ensures a proactive, analytics-enabled approach to program integrity across all lines of business, in line with affordability of care objectives and regulatory requirements. This role is also responsible for external engagement with government organizations and stakeholders and driving Program Integrity Subcommittee activities. The ideal candidate brings at least 7+ years of deep experience in program integrity, fraud, waste and abuse (FWA), Special Investigations Unit (SIU), payment integrity, compliance, and/or related regulatory environments, along with a strong understanding of government-sponsored healthcare programs, particularly Medicaid. This individual has a proven track record of influencing senior leaders, building cross-functional alignment, and partnering effectively with external stakeholders such as regulators, government agencies, and industry organizations. A strategic and highly credible leader who can establish program rigor, navigate complex business and regulatory challenges, and translate analytics and insights into meaningful action and organizational outcomes.

Requirements

7+ years of related compliance/fraud, waste, and abuse (FWA) professional experience.
Bachelor’s degree; in lieu of a degree, an additional two years of relevant experience beyond the qualifications listed above may be accepted.

Nice To Haves

Master's degree in related field.
Ability to translate complex information into actionable messaging, actively listen to diverse perspectives, and drive alignment across cross-functional priorities.
Ability to analyze complex challenges, evaluate tradeoffs, and collaborate with stakeholders to reach effective, lasting solutions.
Ability to effectively organize work, balance shifting priorities, and manage time across multiple workstreams to meet commitments.
Business analysis expertise, regulatory research, and ability to translate regulatory requirement into operation.
Ability to interpret and apply applicable federal and state regulations.
Healthcare or insurance industry experience.
Experience with Medicare/Medicaid regulatory programs.
Experience with CMS, DOH, and state regulatory filings.
Experience drafting responses or presenting to boards, compliance committees, or regulatory bodies.
Certified Compliance & Ethics Professional (CCEP) - Society of Corporate Compliance and Ethics (SCCE), Certified Fraud Examiner (CFE) - Association of Certified Fraud Examiners (ACFE), Certified in Healthcare Compliance (CHC) - Health Care Compliance Association (HCCA), Certified in Healthcare Privacy Compliance (CHPC) - Health Care Compliance Association (HCCA)

Responsibilities

Develop and execute the enterprise Program Integrity strategy, aligning fraud, waste, and abuse (FWA) initiatives with affordability goals, regulatory requirements, and organizational priorities.
Develop and maintain relationships with appropriate regulators, law enforcement, and industry groups. These relationships will include Minnesota elected and appointed leaders at the state, county, and local level; members of the U.S. Congress, and healthcare and business organizations, CMS, and DHS in an ever-increasing regulatory environment as health reform moves forward. Other external relationships may include the national Blue Cross and Blue Shield Association and other Blue Cross Blue Shield plans
Oversee enterprise FWA risk management, including prevention, detection, monitoring, governance, and continuous improvement of risk mitigation strategies.
Provide strategic leadership for Program Integrity governance, including executive and board-level reporting, committee oversight, and organizational thought leadership.
Ensure compliance with federal and state regulations, support audits and investigations, and maintain relationships with regulators, industry organizations, law enforcement, and government stakeholders.
Lead development of analytics, dashboards, KPIs, and reporting to measure program effectiveness, financial impact, savings, and risk exposure while translating insights for executive leadership.
Lead cross-functional collaboration across clinical, network, pharmacy, operations, finance, legal, compliance, SIU, and analytics teams to strengthen program integrity controls and mitigate risk.
Influence enterprise initiatives, payment models, products, and vendor strategies to embed program integrity and compliance requirements.
Partner with Finance and business leaders to validate savings methodologies, quantify cost avoidance, and advance enterprise affordability and total cost of care objectives.
Performs additional responsibilities consistent with the scope and level of the role, as assigned.