Program Integrity Lead

BerryDunn•Remote,

19h•$95,000 - $130,000•Remote

About The Position

BerryDunn is seeking a Program Integrity Lead to support Hawaiʻi Med-QUEST (MDQ). This role will lead Medicaid program integrity activities related to fraud, waste, and abuse prevention; provider oversight; compliance monitoring; risk assessment; external audit coordination; recovery efforts; and Medicaid medical, dental, behavioral health, and pharmacy claims audits. The Program Integrity Lead will coordinate project priorities, client needs, vendor collaboration, Jira tracking, deliverable development, workgroup activity, and leadership reporting to support clear accountability, timely escalation, and consistent execution. This role will help stand up and mature MQD’s Program Integrity function by building foundational processes, strengthening operational rigor, supporting staff adoption, and preparing the unit for long-term sustainability and transition to MQD ownership. Travel expectations: This role may require travel up to 25% of the year.

Requirements

Strong leadership, communication, facilitation, organization, and attention to detail.
Knowledge of Medicaid program integrity, fraud, waste, and abuse prevention, provider oversight, claims review, audit support, compliance monitoring, or related public sector healthcare operations.
Knowledge of quality assurance/control procedures, corrective action tracking, and proactive problem management.
Demonstrated ability to work effectively in a team setting and coordinate across multiple stakeholders, including clients, vendors, project leadership, and internal teams.
Experience using Jira or similar project management tools to track action items, status, ownership, deadlines, risks, blockers, dependencies, and deliverables.
Experience coordinating recurring meetings, documenting follow-up items, maintaining workstream alignment, and supporting escalation pathways.
Strong experience with Microsoft applications and artificial intelligence tools.
Minimum 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)—may substitute four years of applicable experience for the degree.

Nice To Haves

Prior consulting experience in a national or regional consulting firm, experience working in or with a state Medicaid agency, and/or experience supporting Medicaid program integrity, audit, compliance, or claims operations.
Experience supporting healthcare, government, public sector, or Medicaid initiatives preferred.
Experience managing complex projects involving multiple stakeholders, vendors, workstreams, risks, issues, and deliverables.
Experience standing up, stabilizing, training on, or transitioning new operational units, programs, processes, or business functions.
Candidates with certifications such as Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), Certified Professional Medical Auditor (CPMA), Certified Internal Auditor (CIA), or equivalent credentials.

Responsibilities

Serve as a workstream lead for Program Integrity, audit, policy, process, and systems-related activities.
Lead Medicaid program integrity activities, including fraud, waste, and abuse prevention; provider oversight; compliance monitoring; risk assessment; recovery efforts; and external audit coordination.
Lead the stand-up and stabilization of Program Integrity unit functions, including foundational processes, operating rhythms, documentation, roles, decision points, and quality controls.
Build practical structure and rigor for Program Integrity operations, including repeatable workflows, reporting routines, escalation pathways, audit processes, corrective action tracking, and performance monitoring.
Review and audit Medicaid medical, dental, behavioral health, and pharmacy claims for accuracy, legality, reasonableness, and alignment with Medicaid policies, regulations, billing requirements, and claims data.
Interpret and apply Medicaid policy, federal and state requirements, and applicable code of federal regulations to support compliant program operations.
Establish and monitor program integrity objectives, key performance indicators (KPIs), corrective action plans, and reporting processes.
Analyze claims data, audit results, program integrity reports, recovery information, and related documentation to identify risks, trends, findings, and improvement opportunities.
Develop or update policies, procedures, requirements, guidance, recommendations, training materials, and related program integrity documentation.
Partner with MQD leadership and staff to support adoption of new Program Integrity processes, tools, expectations, and ways of working.
Develop training, guidance, job aids, and transition materials to help MQD staff operate and sustain Program Integrity processes over time.
Support knowledge transfer and handoff planning so Program Integrity responsibilities, documentation, tools, and operating practices can transition to MQD ownership at the appropriate time.
Coordinate priorities, assignments, action items, risks, blockers, dependencies, and follow-up activities across stakeholders, BerryDunn team members, vendor partners, and project leadership.
Lead or co-lead workstream meetings, workgroups, planning sessions, and internal alignment discussions to support timely decisions, clear communication, and consistent follow-through.
Maintain accurate workstream information in Jira, including tasks, action items, blockers, milestones, status notes, due dates, dependencies, priorities, and reporting updates.
Support weekly and monthly project reporting, closeout materials, leadership updates, and client-facing status information.
Review workstream documents, meeting notes, deliverables, recommendations, and client-facing materials for accuracy, consistency, quality, and alignment with project standards.
Use SharePoint/KnowledgeLink to organize, maintain, and version project documentation consistent with document management expectations.
Escalate risks, blockers, decisions, and support needs early through the appropriate workstream and project management pathways.