Medicaid Program Integrity Lead - Hybrid IA

Texas Health Institute; Des Moines, Northern (IA, KY); Hybrid; USD 77,000 - 116,000; Full time

Job summary

Sun Life U.S. seeks an experienced Iowa Program Integrity Manager to lead Medicaid program integrity operations, including special investigations and collaboration with state and federal partners. The role concentrates on preventing fraud, waste, and abuse while aligning with Medicaid rules and CMS requirements.

You will oversee data-driven reviews, manage cross-functional teams, and coordinate with state agencies to safeguard program integrity in a large health plan environment.

Qualifications

• Bachelor's degree from an accredited four-year college or university is required.
• 9+ years of experience in compliance, legal or regulatory functions or related fields.
• Experience managing health care delivery, program integrity, utilization management, or public health program functions in a large health plan.
• Comprehensive knowledge of Medicaid Managed Care laws and regulations.
• Ability to use knowledge and metrics to improve program integrity priorities and results.
• Experience in senior leadership roles with government agencies, law enforcement, or related organizations.

Responsibilities

• Provide leadership and strategic oversight of Program Integrity and SIU activities.
• Participate in Fraud, Prevention, and Recovery operations to prevent, detect and investigate fraud, waste, and abuse.
• Collaborate with Clinical Quality Management to improve fraud, waste, and abuse prevention.
• Develop and implement program integrity strategies aligned with Iowa Medicaid rules.
• Perform advanced data analysis to identify utilization trends and risks.
• Collaborate with state Medicaid agencies, CMS, MCOs, and law enforcement.
• Partner with Dental Directors to ensure investigations are clinically sound.
• Ensure all investigative actions comply with CMS rules and internal policies.
• Serve as primary client liaison for fraud investigations and meetings.
• Track investigations and workflows, including client reporting.
• Support policy improvements and interdepartmental collaboration.

Skills

Regulatory compliance

Healthcare program integrity

Data analysis

Policy writing

Stakeholder management

Leadership

Communication

Regulatory liaison

Education

Bachelor's degree in a related field

Tools

PowerPoint

Excel

Job description

Sun Life U.S. seeks an experienced Iowa Program Integrity Manager to lead Medicaid program integrity operations, including special investigations and collaboration with state and federal partners. The role concentrates on preventing fraud, waste, and abuse while aligning with Medicaid rules and CMS requirements.

You will oversee data-driven reviews, manage cross-functional teams, and coordinate with state agencies to safeguard program integrity in a large health plan environment.