Program Integrity Director

Noridian Healthcare Solutions, LLC•Fargo, ND

5d•$104,831 - $172,421•Remote

About The Position

The Program Integrity Lead defines and leads Noridian's enterprise Program Integrity strategy, with a primary focus on Medicare programs and initiatives that advance fraud, waste, and abuse prevention, payment integrity, medical review, provider audits, data analytics, and compliance operations. Serving as Noridian's strategic authority in Program Integrity, this leader identifies opportunities to strengthen Medicare contracts, expand service capabilities, drive innovation for Centers for Medicare & Medicaid Services (CMS) and other federal customers, and improve operational performance. The role is accountable for developing and executing a multi-year strategy that enhances contract value, supports revenue growth, advances CMS objectives, and positions Noridian as an industry leader in Program Integrity.

Requirements

Bachelor's degree in Business, Healthcare Administration, Public Administration, Data Analytics, Nursing, Health Information Management, or related field OR equivalent work experience.
10 years of progressive experience in healthcare, Medicare, Medicaid, federal health programs, audit, compliance, or Program Integrity, including 7 of those years serving in a leadership capacity or leading initiatives across Program Integrity, payment integrity, medical review, audit, compliance, operations, or related functions.
Demonstrated experience developing enterprise strategies and translating them into operational execution plans.
Strong knowledge of Medicare operations, CMS programs, and federal healthcare contracting.
Experience presenting to senior executives and external stakeholders.
Exceptional communication, relationship management, and strategic planning skills.
Ability to read, hear, speak, keyboard, reason, communicate effectively and problem solve
Requires prolonged sitting and telephone usage
Requires the use of office equipment such as computer terminals, telephones, copiers, and printers
Infrequent lifting to 20 pounds
Infrequent stooping

Nice To Haves

Master's degree, such as MBA, MHA, MPH, or related field.
Experience with Medicare Administrative Contractor, Supplemental Medicare Review Contractor (SMRC), Unified Program Integrity Contractor (UPIC), RAC, or other CMS Program Integrity programs.
Experience leading or managing a Program Integrity function within a federal or state government agency, with demonstrated responsibility for oversight of fraud, waste, and abuse prevention, compliance activities, investigative operations, audit programs, and/or payment integrity initiatives in a publicly funded program environment.
Experience with AI, predictive analytics, fraud detection technologies, or healthcare data platforms.
Experience supporting federal business development and growth initiatives.
Lean, Six Sigma, Project Management, or Change Management certification.

Responsibilities

Develops and maintains Noridian's enterprise Program Integrity strategy and roadmap.
Establishes a future-state vision for Program Integrity capabilities across Medicare operations.
Creates executive recommendations regarding investments, technology, partnerships, staffing models, and operational enhancements.
Develops and executes a growth strategy focused on expanding Program Integrity work within Noridian's existing Medicare and Medicaid contracts as well as new bid opportunities.
Identifies opportunities to increase contract value through additional CMS scope, new demonstrations and pilots, Program Integrity authorities, provider audit services, advanced analytics capabilities, automation and AI solutions, and medical review modernization.
Builds business cases supporting additional Medicare work and contract modifications.
Translates approved strategies into executable operational plans.
Establishes performance metrics and dashboards to monitor financial impact, quality outcomes, operational performance, customer satisfaction, compliance effectiveness, and program return on investment.
Ensures alignment between Program Integrity initiatives, quality strategy, compliance requirements, and enterprise objectives.
Partners with Business Development, Government Affairs, Customer Relations, and Operations leaders to position Noridian as a trusted CMS advisor.
Supports customer engagement efforts by preparing thought leadership materials, CMS presentations, concept papers, and value propositions.
Builds relationships with CMS leaders, Medicare stakeholders, industry partners, vendors, and professional organizations.
Represents Noridian in industry forums, conferences, customer discussions, and strategic planning sessions.
Advises senior leadership regarding investment decisions, emerging technologies, and future Program Integrity opportunities.
Fosters collaboration between operational, technical, clinical, compliance, and business development teams.
Identifies emerging CMS priorities, regulatory trends, fraud schemes, payment integrity initiatives, and policy changes that may create risks or opportunities.
Evaluates and recommends opportunities involving medical review, provider audits, data analytics, prior authorization, fraud prevention, predictive analytics, payment integrity, and AI-enabled Program Integrity solutions.
Evaluates external partnership opportunities that strengthen Noridian's Program Integrity capabilities and competitive position.
Defines implementation roadmaps, timelines, business cases, success measures, and governance models.
Oversees pilot programs and innovation efforts from concept through operational deployment.
Champions innovation and continuous improvement initiatives that enhance Program Integrity outcomes.
Leads cross-functional teams responsible for execution.
Partners with Operations, Technology, Continuous Improvement and Quality, Data and Analytics, Customer Relations, Clinical Services, and Business Development teams to implement initiatives.
Serves as the primary internal consultant and subject matter expert on Program Integrity strategy.
Other duties as assigned.