Medicaid Program Integrity Lead — Stand Up & Oversight

BerryDunn; United States; Remote; USD 95,000 - 130,000; Full time

Job summary

BerryDunn is seeking a Program Integrity Lead to guide Medicaid program integrity activities for Hawaiʻi Med-QUEST. You will oversee fraud, waste, and abuse prevention, provider oversight, and compliance monitoring, coordinating with vendors and stakeholders to mature MQD's Program Integrity function.

The role requires strong leadership and a track record in Medicaid integrity, audits, and policy interpretation, with up to 25% travel.

Qualifications

• Leadership and program management experience in Medicaid program integrity or related healthcare operations.
• Experience with audit, compliance monitoring, and policy application in public sector healthcare.

Responsibilities

• Serve as workstream lead for Program Integrity, audit, policy, process, and systems-related activities.
• Lead Medicaid program integrity activities including fraud, waste, and abuse prevention; provider oversight; compliance monitoring; risk assessment; recovery efforts; and external audit coordination.
• Stand up and stabilize Program Integrity unit functions with foundational processes, operating rhythms, documentation, roles, decision points, and quality controls.
• Build repeatable workflows, reporting routines, escalation pathways, audit processes, corrective action tracking, and performance monitoring.
• Review Medicaid claims for accuracy, legality, reasonableness, and alignment with policies and billing requirements.
• Interpret and apply Medicaid policy, federal/state requirements, and CFR to support compliant operations.
• Establish and monitor program integrity objectives, KPIs, corrective action plans, and reporting processes.
• Analyze claims data, audit results, program integrity reports, and related documentation to identify risks and improvement opportunities.
• Develop or update policies, procedures, guidance, and training materials for program integrity.
• Partner with MQD leadership to support adoption of new processes, tools, and ways of working.
• Develop training, job aids, and transition materials to help MQD staff sustain processes.

Skills

Leadership

Communication

Facilitation

Organization

Attention to detail

Medicaid program integrity

Quality assurance

Team coordination

Jira

Microsoft applications

AI tools

Education

Bachelor's Degree

Tools

Jira

SharePoint

KnowledgeLink

AI tools

Job description

BerryDunn is seeking a Program Integrity Lead to guide Medicaid program integrity activities for Hawaiʻi Med-QUEST. You will oversee fraud, waste, and abuse prevention, provider oversight, and compliance monitoring, coordinating with vendors and stakeholders to mature MQD's Program Integrity function.

The role requires strong leadership and a track record in Medicaid integrity, audits, and policy interpretation, with up to 25% travel.