Program Integrity Contract Lead

NEPSE Trading; United States; Remote; USD 110,000 - 150,000; Full time

Job summary

NEPSE Trading is seeking a PI Contract Lead to join the leadership team. You will work with Program Integrity leadership, the Compliance Officer, and the Compliance Committee to ensure contract compliance with federal health care programs, FAR, and related regulations. You will analyze processes and drive measurable improvements.

You will identify risks, perform root cause analyses, prepare data reports, and support implementation of corrective actions. This role requires U.S.

Qualifications

• 5+ years of Program Integrity and/or Payment Integrity experience.
• 2+ years of project management experience (ideally in implementing large contracts).
• U.S. citizenship required for this position (DoD contract).
• Ability to obtain government security clearance (NBIS).
• Experience reading and interpreting contracts, policies, and operations manuals.

Responsibilities

• Translate contract requirements into business processes, workflows, controls, procedures, and operational requirements.
• Identify operational gaps and recommend changes to meet contractual requirements; support SOPs and training materials.
• Establish and maintain a contract monitoring framework with SLAs, KPIs, deliverables, and milestones.
• Apply Lean, Six Sigma, root cause analysis and other process improvement methodologies.
• Review contract requirements and ensure alignment of operational processes with obligations.

Skills

Program Integrity

Project management

Data analysis

Root cause analysis

Contract interpretation

Communication

Presentations

Microsoft Office

Education

RN/BSN

CPC

CCS

CCDS

CHC

HCAFA

AHFI

CFE

JD

Tools

Microsoft Excel

PowerPoint

Word

Job description

Become a part of our caring community The Program Integrity (PI) Contract Lead is an important member of the leadership team and works directly with Program Integrity Leadership, the Compliance Officer, and the Compliance Committee. This position requires a strong understanding of the VA Community Care Network (CCN) program, including, but not limited to, federal health care program requirements, Executive Order 12549, Federal Acquisition Regulation (FAR) Part 3, the Federal False Claims Act, and applicable state and federal laws governing program integrity and compliance. The PI Contract Lead analyzes and evaluates the effectiveness of existing business processes and develops sustainable, repeatable, and measurable process improvements. You will participate in and influence departmental and cross-functional strategy discussions, recommending changes needed to maintain compliance with contractual obligations and regulatory requirements. You will address issues of varied scope and complexity, ranging from moderate to significant. The PI Contract Lead works collaboratively with key stakeholders to provide consultative support, internal briefings, training, and participation in integrated care planning, as needed.

You will partner with stakeholders to identify, develop, and implement corrective actions. Responsibilities include performing root cause analyses, escalating significant concerns to leadership, and recommending functional strategies to address identified risks or gaps. Decisions may involve resource allocation, operational approach, tactical execution, and department-level initiatives. Administrative responsibilities include, but are not limited to, preparing and maintaining Contract Data Requirements List (CDRL) reports; managing the Program Integrity library, including letters, job aids, and process flow documentation; reviewing associate documentation and tools; analyzing data findings; and briefing the team on key results and recommendations. The PI Contract Lead also provides support to data and technology teams in the development of business and financial models.

KEY ACCOUNTABILITIES

• 35% Translate contract requirements into business processes, workflows, controls, procedures, and operational requirements. Develop implementation workplans, milestones, dependencies, risks and readiness criteria for projects
• 25% Identify operational gaps and recommend process changes necessary to meet contractual requirements. Support development of standard operating procedures, desk level procedures, workflows, job aids and training materials.
• 15% Establish and maintain an ongoing contract monitoring framework to ensure continued compliance with contractual requirements. Monitor contract performance, service level agreements, key performance indicators, deliverables, milestones, and operational commitments.
• 15% Apply Lean, Six Sigma, root cause analysis and other process improvement methodologies to improve operational and contract performance.
• 10% Conduct routine reviews of contract requirements to ensure operational processes remain aligned with current contractual obligations.

This role description in no way states or implies that the key accountabilities above are the only ones being performed by the individual(s) with this role description. The individual(s) may be called upon and required to follow other instructions or perform other duties and tasks requested by his or her supervisor, consistent with the purpose of the position, department and/or company objectives. Use your skills to make an impact

Required Qualifications

• 5 or more years of Program Integrity and/or Payment Integrity experience
• 2 or more years of project management (Ideally in implementing large contracts) experience
• Must have ONE of the following ant-fraud degrees, designations, and/or certifications : -Registered Nurse/Bachelor of Science in Nursing (RN/BSN) -Certified Profession Coder (CPC) -Certified Coding Specialist (CCS) -Certified Clinical Documentation Specialist (CCDS) -Certification in Healthcare Compliance (CHC) -Health Care Anti-Fraud Associate (HCAFA) -Accredited Health Care Fraud Investigator (AHFI) -Certified Fraud Examiner (CFE) -Juris Doctorate (JD)
• Current experience with understanding claims adjudication, systems and reporting
• Knowledge in healthcare related applications and technology
• Ability to manage and prioritize multiple initiatives with minimal guidance
• Excellent communication and presentation skills to include the ability to communicate and present technical details to senior and executive level leadership
• Results-driven mindset with the ability to achieve established individual and organizational goals
• Experienced in researching and analyzing data to determine root cause within areas of opportunity
• Experience reading and interpreting documents such as contracts, policy and operations manuals
• High level problem-solving and analytical experience
• Proficiency in Microsoft office suite Excel, PowerPoint and Word
• Our Department of Defense Contract requires U.S. citizenship for this position
• Successfully receive approval for government security clearance (Via National Background Investigation Services NBIS)
• HGB is not authorized to do work in Puerto Rico per our government contract.
• We are not able to hire candidates that are currently living in Puerto Rico

Preferred Qualifications

BA in Business, HealthCare Administration or Operations Management Lean Six Sigma and/or Project Management Experience/Certificate Knowledge and experience working with Government programs to include VA, Medicare and/or TRICARE Previous experience managing or leading programs, technical implementations and/or initiatives Prior experience with Workflow design and Business Process Optimization Ability to learn a complex processing system

Additional Information

Work Style : Remote Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of H