Program Integrity Manager
About The Position
The Program Integrity Manager serves as a key leader supporting Medicaid Program Integrity, Payment Integrity, and Special Investigations Unit (SIU) activities for the New Jersey Medicaid Health Plan. This role is responsible for ensuring compliance with state and federal requirements, supporting fraud, waste, and abuse (FWA) prevention efforts, overseeing regulatory and contractual obligations, coordinating reporting and audit activities, and partnering with internal and external stakeholders to promote operational effectiveness and program integrity. The position works closely with health plan leadership, Compliance, Legal, Clinical, Provider Relations, Analytics, Operations, SIU, and external vendors to drive strategic initiatives, lead cross-functional projects, facilitate meetings and workgroups, and identify opportunities for innovation and process improvement. The Program Integrity Manager must be able to influence stakeholders, obtain buy-in, present to diverse audiences, and lead initiatives from concept through implementation.
Requirements
- 5+ years of experience in Program Integrity, Payment Integrity, SIU, Healthcare Compliance, FWA, Claims Operations, Healthcare Operations, or a related field, including experience in a leadership, supervisory, management, or project lead capacity.
- Knowledge of healthcare regulatory and compliance requirements.
- Strong analytical, organizational, communication, and problem-solving skills.
- Demonstrated experience leading projects, initiatives, meetings, and cross-functional workgroups.
- Experience partnering with multiple business areas and external stakeholders to achieve business objectives.
- Strong presentation and facilitation skills with the ability to communicate effectively to leadership and stakeholder groups.
- Proven ability to drive process improvements, lead ideation efforts, gain stakeholder buy-in, and influence decision-making.
- Ability to manage multiple priorities and work effectively in a collaborative environment.
Nice To Haves
- Experience supporting Medicaid managed care programs.
- Experience with regulatory reporting, audits, compliance initiatives, or operational oversight activities.
- Experience working with SIU investigations, fraud prevention programs, vendor management, or payment integrity operations.
- Knowledge of healthcare claims, provider reimbursement, payment accuracy, and program integrity practices.
- Project management experience leading strategic or operational initiatives across multiple business partners.
Responsibilities
- Ensuring compliance with state and federal requirements
- Supporting fraud, waste, and abuse (FWA) prevention efforts
- Overseeing regulatory and contractual obligations
- Coordinating reporting and audit activities
- Partnering with internal and external stakeholders to promote operational effectiveness and program integrity
- Driving strategic initiatives
- Leading cross-functional projects
- Facilitating meetings and workgroups
- Identifying opportunities for innovation and process improvement
- Influencing stakeholders, obtaining buy-in, presenting to diverse audiences, and leading initiatives from concept through implementation
Benefits
- medical
- dental
- vision coverage
- paid time off
- retirement savings options
- wellness programs
- other resources, based on eligibility
- CVS Health bonus, commission or short-term incentive program
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What This Job Offers
Job Type
Full-time
Career Level
Manager
Education Level
Associate degree
