Team Lead, Program Integrity (Triage)
About The Position
The Team Lead, Program Integrity drives and encourages innovative investigative processes and workflows to reduce turnaround time and produce positive investigative outcomes. This role involves directing the day-to-day activities and leadership of investigative staff, serving as an investigative planning consultant, assigning cases, and monitoring/prioritizing investigation allocation to maximize output and effectiveness. The position also focuses on identifying knowledge gaps, providing training opportunities, leading staff meetings, coordinating training for new and existing staff, and mentoring direct reports. Additionally, the Team Lead will identify workflow and process inefficiencies, develop and implement standard operating procedures, and collaborate cross-functionally. A key aspect of the role is proactively using analytic skills to identify potential areas of Fraud, Waste, and Abuse (FWA) and recommending future investigations. The Team Lead will also assist department leadership in implementing program integrity metrics, performance indicators, and AI agents/workflows, while staying current on healthcare fraud trends and schemes. This role requires performing investigative case work, contributing to case creation and lead generation, and performing any other job-related duties as requested.
Requirements
- Bachelor's degree in Health-Related Field, Law Enforcement, or Insurance required
- Five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics or related field required
- Intermediate proficiency in Microsoft Outlook, Word, Excel, Access, and Power Point
- Ability to formally present to a wide audience
- Ability to work independently and in a team environment with a high level of confidence
- Highest levels of ethics, integrity, ethics and professionalism in performance of all duties
- Excellent problem solving and decision-making skills with attention to details
- Demonstrated ability in research and drawing conclusions
- Ability to perform intermediate data analysis and to articulate understanding of findings
- Ability to work under limited supervision with moderate latitude for initiative and independent judgment
- Demonstrated leadership skills
- Self-motivated and self-directed
- Knowledge of government program compliance requirements – Medicare, Medicaid, Affordable Care Act (ACA), etc.
- One of the following certifications is required: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) required
Nice To Haves
- Master's degree (e.g., criminal justice, public health, mathematics, statistics, health economics, nursing) preferred
- Equivalent years of relevant work experience may be accepted in lieu of required education
- Supervisory or leadership experience preferred
- Medical terminology, CPT, HCPCS, ICD codes or medical billing knowledge preferred
- Knowledge of medical insurance and/or state regulatory requirements
- Certified Professional Coder (CPC) preferred
- NHCAA or other fraud and abuse investigation training preferred
Responsibilities
- Direct the day-to-day activities and leadership of investigative staff to ensure goals of the department are met
- Serve as investigative planning consultant to investigative teams
- Assign cases to investigative staff
- Monitor and prioritize investigation allocation to maximize output and effectiveness of staff to ensure requirements and standards are achieved
- Identify knowledge gaps and provide training opportunities to direct reports
- Lead, arrange and conduct SIU staff meetings
- Coordinate the training of new and existing investigative staff to increase recognition of fraud and abuse indicators and properly direct workflows
- Mentor direct reports including, coaching, development, performance feedback, disciplinary issues, and annual performance evaluations
- Identify workflow and process inefficiencies
- Identify, recommend, develop, and implement internal departmental standard operating procedures
- Collaborate cross functionally between investigative teams and other matrix partners
- Proactively use analytic skills to identify potential areas of FWA and recommend future investigations
- Assist department leadership in identifying, planning, and implementing program integrity metrics and performance indicators
- Assist department leadership in identifying, planning, and implementing Artificial Intelligence (AI) agents and AI-enabled workflows
- Maintain knowledge and stay current on Health Care Fraud trends and schemes
- Recommend process or procedure changes and work with cross departmental teams on identified internal system gaps to mitigate FWA or financial risk
- Assist in response to state and federal regulatory audits
- Identify, assess and control risk to achieve compliance with state and federal integrity rules
- Perform investigative case work and contribute to case creation and lead generation
- Perform any other job related duties as requested
Benefits
- In addition to base compensation, you may qualify for a bonus tied to company and individual performance.
- We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
