Sr. Director, Program Integrity

Public Partnerships•Albany, NY

1d•Remote

About The Position

The Senior Director, Program Integrity provides strategic and operational leadership over the organization’s enterprise‑wide fraud, waste, and abuse (FWA) program, ensuring regulatory compliance, risk mitigation, and program effectiveness across all states. Reporting to the Vice President, Compliance, this role serves as the primary senior liaison with regulatory and law enforcement agencies, including OMIG and MFCUs, and oversees fraud detection, investigation, audit readiness, and corrective action management. The Senior Director establishes governance frameworks, drives data‑informed integrity initiatives, standardizes processes across markets and health plan partners, and leads continuous improvement efforts to identify emerging risks, strengthen controls, and promote a culture of accountability and compliance.

Requirements

Excellent knowledge of relevant laws, regulations and industry standards
CDPAP and Medicaid experience
Experience managing relationships with MFCUs and state oversight agencies
Ability to communicate complex compliance issues clearly and effectively
Expert in FWA and ANE investigative processes
Strong analytical, interpersonal, and organizational skills
Proficiency in Microsoft Office technology; comfortable learning new systems and communicating system design needs
Demonstrated competence in reviewing contracts and other legal and regulatory documents
Strong attention to detail and process improvement
Excellent written and oral communication skills
Ability to negotiate with partners for prioritization and resource allocation
Comfortable with healthy conflict
Skilled at developing and maintaining accountability within corporations
Demonstrated ability to build highly effective teams and manage staff
Strong work ethic and ability to prioritize tasks in a fast-paced, dynamic environment
Bachelor’s degree preferred; Substantial professional experience may be considered in lieu of a formal degree.
10+ years of relevant work experience in a compliance leadership role required
5+ years of leadership experience
Experience with fraud waste and abuse prevention, detection, investigation and management in healthcare
Experience in managing regulatory relationships and audits (both internal and external) required
Experience with government contracts and familiarity with Medicaid

Nice To Haves

CFE or AHFI highly desirable

Responsibilities

Map, maintain, and continuously update a comprehensive inventory of all relevant state program integrity agencies, including MFCUs and state Medicaid integrity units
Serve as the primary point of contact with regulators, including OMIG, MFCUs, and other law enforcement and oversight entities
Establish and maintain strong, credible relationships with regulatory partners to support collaboration, transparency, and trust
Collaborate with Health Plans in fraud, waste and abuse investigation and referral processes.
Oversee and standardize fraud, waste, and abuse referral processes across all states, ensuring timeliness, completeness, and regulatory compliance
Monitor evolving regulatory expectations and ensure program alignment with federal and state requirements
Design and implement an enterprise-wide program integrity framework aligned with organizational risk, regulatory expectations, and industry best practices
Develop and maintain a centralized fraud risk register, including risk identification, scoring, mitigation strategies, and ownership
Establish governance structures for fraud oversight, including reporting to executive leadership and compliance committees
Catalogue and continuously update fraud prevention and detection best practices across the organization
Oversee fraud investigation and auditing
Ensure effective intake, triage, investigation, and resolution of suspected fraud, waste, and abuse cases
Provide strategic direction and oversight for complex, high-risk investigations
Ensure proper documentation, case management, and audit readiness
Monitor and ensure execution of corrective action plans (CAPs) resulting from investigations, audits, and regulatory findings
Oversee the design, implementation, and continuous enhancement of program integrity dashboards and reporting tools
Partner with data/analytics teams to develop predictive and retrospective fraud detection methodologies
Establish KPIs and performance metrics for fraud detection, investigation efficiency, and prevention impact
Quantify and report cost savings and cost avoidance resulting from fraud prevention and detection initiatives
Leverage data mining and trend analysis to identify emerging fraud schemes and risk areas
Lead the development and execution of fraud prevention initiatives, including pre-payment controls and policy enhancements
Identify systemic vulnerabilities and implement proactive interventions to mitigate risk
Drive continuous improvement through benchmarking, regulatory insights, and industry collaboration
Support training and awareness programs related to fraud, waste, and abuse