Program Integrity Manager - Medicare/Medicaid

Peraton

2d•Remote

About The Position

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse. This key personnel position requires demonstrated experience managing staff and investigative functions within the healthcare fraud, waste, and abuse (FWA) domain. The role is responsible for planning, directing, and overseeing investigative workload related to CMS contracts supporting the Medicare and Medicaid lines of business. Key responsibilities include recruiting, developing, and mentoring staff while providing strategic and operational guidance to data analysts, investigators, and medical review professionals to ensure daily performance standards and CMS metrics are consistently met. The successful candidate will maintain strong and collaborative relationships with CMS, law enforcement agencies, Medicare Administrative Contractors (MACs), and other internal and external stakeholders. The role includes oversight and management of all program integrity functions across the SE UPIC, complex, multi-subject investigations involving organized criminal enterprises, including the execution of simultaneous on-site provider visits in CMS-designated high-risk areas. This position also requires close coordination with the Office of Inspector General (OIG), the Federal Bureau of Investigation (FBI), the Department of Justice (DOJ) and State Medicaid Agencies within the SE UPIC jurisdiction. The ideal candidate will demonstrate strong leadership capabilities, including advanced problem-solving skills, effective delegation, delivery of constructive and meaningful feedback, conflict resolution, and the ability to motivate and engage staff to consistently meet and exceed contractual obligations.

Requirements

Bachelors degree from an accredited institution and 12 years of related experience.
A minimum of 8 or more years of professional experience, with at least 3 years in management capacity responsible for complex systems, workflows, and investigative priorities, to include application of administrative actions to address complex fraud schemes.
Proven leadership skills and in-depth knowledge of the Medicare and Medicaid Programs as it pertains to reviewing claims and provider behavior for indications of potential fraud, waste, and abuse.
Knowledge of Medicare and Medicaid requirements, laws, rules, and regulations related to payment for services billed to the Program.
Demonstrated experience and knowledge in providing guidance to data analysts, investigators, and medical staff.
Demonstrated experience applying regulations and customer guidelines to implement and coordinate appropriate administrative actions, to include payment suspensions, revocations, overpayment processing, prepayment claim review, and post payment claim review.
Demonstrated experience presenting on current investigative outcomes and focusing resources to address emerging fraud trends, customer expectations, and presenting cases for coordination with external partners.
Must obtain CMS approval and pass minimum contractual requirements found in the UPIC Statement of Work.
U.S. citizenship required.

Nice To Haves

Expert representational, oral, and written communication skills.
Master’s degree or other graduate degree from an accredited institution.
Superior organizational and interpersonal skills and demonstrated ability to interface effectively via written and oral forums with personnel at all levels of government.
Expert skills using MS Office Suite, including Outlook, Word, Excel, and PowerPoint.
Ability to effectively work independently and as a member of a team.
A strong background in Medicare/Medicaid investigations including the full life cycle of a program integrity investigation including administrative actions.

Responsibilities

Proven ability to meet and exceed business goals and targets.
Demonstrate leadership that encourages innovation
Accountable for the successful execution of the current business as well as for the growth and expansion of the Medicare and Medicaid accounts when available.
Ability to motivate staff and evaluate performance.
Plan resources to address workload needs, set priorities, and report unit activity.
Assist in development, administration of, and oversight control the Medicare and Medicaid budget.
Administer corporate polices.
Responsible for recruiting, interviewing, and hiring staff.
Ability to oversee contract requirements for Medicare and Medicaid
Act as the primary point-of-contact for coordination of customer investigative priorities, collaboration on investigative outcomes, and coordinating investigative outcomes aligned with Medicare and Medicaid regulations.
Ensure all contract requirements are met including quality, cost control, timeliness, and business relations for Medicare and Medicaid
Ability to maintain superior business relations with CMS, Law Enforcement, MACs and all other stakeholders and partners.