Program Integrity Manager, DentaQuest - Must Reside in Iowa

Sun Life•Des Moines, IA

20h•Hybrid

About The Position

Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work in the contiguous states plus AK. Candidate Must Reside in Iowa. The opportunity : Reporting to the Director of Regulatory Compliance & Program Integrity, the Iowa Program Integrity Manager is accountable for leading and overseeing a Medicaid Managed Care program integrity operation, providing strategic direction, leadership, and oversight of special investigations and activities to prevent and address fraud, waste, and abuse. This role collaborates closely with state Medicaid administrators, CMS, federal and state law enforcement, and managed care organizations to develop, implement, and continuously improve program integrity strategies, policies, and systems. The position requires senior-level experience in healthcare delivery and program integrity, comprehensive knowledge of Medicaid laws and regulations, and the ability to analyze data and trends to drive effective oversight and enforcement actions. Serving as the primary liaison between Sun Life DentaQuest and our client at Iowa Health and Human Services, the Program Integrity Manager is based near Des Moines, Iowa, works full time, and is responsible for ensuring transparency, accountability, and safeguarding the integrity of Medicaid programs through full access to claims, processing data, and investigative resources.

Requirements

Must reside in Iowa
Bachelor’s degree from an accredited four-year college or university is required
9+ years of experience in compliance, legal or regulatory functions or combined education and/or full-time experience in any field and profession in any field (e.g., public or business administration, social work, public health, law, education, engineering)
Demonstrate knowledge and experience in managing health care delivery, program integrity, utilization management, or public health program functions within a large health plan or programs
Comprehensive knowledge of laws, policies, and regulations that apply to the administration of Medicaid Managed Care program health care delivery and program integrity
Demonstrate ability to use knowledge and associated metrics to assess and improve program effectiveness, management processes, and systems to achieve program integrity priorities and results.
Demonstrate experience, in a senior leadership position working with government agencies and programs, law enforcement organizations, and/or public and private organizations on complex and controversial issues related to program integrity
Ability to attend additional training as requested/deemed necessary
Ability to attend in-person regulatory meetings with clients
Ability to evaluate laws and regulations and identify and prioritize relevant content for updating policies and procedures
Ability to interpret laws and regulations and communicate that information to management and line personnel
Ability to research and investigate regulatory issues as they relate to the company’s operating subsidiaries and businesses
Ability to discern risks and recommend controls to mitigate regulatory compliance
Ability to assume a reasonable level of authority, to handle multiple projects and duties at the same time and to work collaboratively in a nonhierarchical department structure
Ability to interface with various levels of management, as well as with internal and external clients and subject matter experts
Strong writing skills, with extensive policy and procedure writing experience required
Strong verbal communication skills
Strong collaborative skills, as well as analytical, problem-solving and decision-making skills
Meticulous organizational skills and attention to detail
Strong PowerPoint and advanced Excel capabilities preferred

Responsibilities

Provide leadership and strategic oversight of DentaQuest Program Integrity and Special Investigations Unit (SIU) activities.
Participate in Fraud, Prevention, and Recovery operations and oversight activities to prevent, detect and investigate fraud, waste, and abuse.
Collaborate with Clinical Quality Management to improve fraud, waste, and abuse prevention activities.
Develop, implement, and continuously improve program integrity strategies aligned with Iowa Medicaid rules and regulations.
Perform advanced data analysis and drill-down utilization reviews to identify under- and over-utilization trends and program risks.
Collaborate with state Medicaid agencies, CMS, managed care organizations, and state and federal law enforcement.
Partner with Dental Directors to ensure investigative decisions are clinically sound, defensible, and properly documented.
Ensure all investigative, audit, and recovery actions comply with CMS rules and regulations and internal policies and procedures.
Serve as primary client and provider liaison for all fraud, waste, and abuse investigations and program integrity client meetings.
Track investigations, manage workflows independently, which include client reporting requirements.
Support policy and procedure improvements and foster interdepartmental collaborations to strengthen program integrity outcomes.