Program Integrity Manager

Jobtailor; Des Moines (IA); On-site; USD 120,000 - 180,000; Full time

Job summary

Jobtailor is seeking a senior leader to oversee the DentaQuest Program Integrity and Special Investigations Unit. The role provides strategic direction for fraud prevention, compliance, and investigations within Iowa Medicaid guidelines.

The position requires deep knowledge of Medicaid managed care regulations, senior leadership experience with government agencies, and strong data analytics capabilities. In-person collaboration with state and federal stakeholders is essential.

Qualifications

• Bachelor’s degree required.
• “9+ years of experience in compliance, legal or regulatory functions” or equivalent.
• Experience with Medicaid Managed Care laws and program integrity preferred.
• Ability to interpret and communicate laws and regulations to leadership.

Responsibilities

• Lead and oversee DentaQuest Program Integrity and Special Investigations Unit activities.
• Provide strategic direction and oversight of special investigations and fraud, waste, and abuse prevention activities.
• Collaborate with state Medicaid agencies, CMS, and law enforcement on investigations and policy.
• Develop, implement, and improve program integrity strategies aligned with Iowa Medicaid rules.
• Perform advanced data analysis to identify utilization trends and program risks.
• Ensure investigative actions comply with CMS rules and internal policies.

Skills

Fraud prevention

Data analysis

Regulatory compliance

Leadership

Policy development

Communication

Investigation skills

Education

Bachelor’s degree

Tools

Excel

PowerPoint

Job description

• Lead and oversee DentaQuest Program Integrity and Special Investigations Unit activities
• Provide strategic direction and oversight of special investigations and fraud, waste, and abuse prevention activities
• Participate in Fraud, Prevention, and Recovery operations and oversight
• Collaborate with Clinical Quality Management to improve fraud, waste, and abuse prevention
• Develop, implement, and continuously improve program integrity strategies aligned with Iowa Medicaid rules and regulations
• Perform advanced data analysis and drill-down utilization reviews to identify under- and over-utilization trends and program risks
• Collaborate with state Medicaid agencies, CMS, managed care organizations, and state and federal law enforcement
• Partner with Dental Directors to ensure investigative decisions are clinically sound, defensible, and documented
• Ensure investigative, audit, and recovery actions comply with CMS rules, regulations, and internal policies
• Serve as primary client and provider liaison for fraud, waste, and abuse investigations and program integrity meetings
• Track investigations and independently manage workflows, including client reporting requirements
• Support policy and procedure improvements and interdepartmental collaboration
• Serve as primary liaison between Sun Life DentaQuest and Iowa Health and Human Services
• Ensure transparency, accountability, and integrity of Medicaid programs through claims, processing data, and investigative resources

Requirements

• Must reside in Iowa
• Bachelor’s degree from an accredited four-year college or university is required
• 9+ years of experience in compliance, legal or regulatory functions, or combined education and/or full-time experience in any field and profession
• Knowledge and experience managing health care delivery, program integrity, utilization management, or public health program functions within a large health plan or program
• Comprehensive knowledge of laws, policies, and regulations applicable to Medicaid Managed Care health care delivery and program integrity
• Ability to use knowledge and metrics to assess and improve program effectiveness, management processes, and systems
• Senior leadership experience working with government agencies and programs, law enforcement organizations, and/or public and private organizations on complex and controversial program integrity issues
• Ability to attend additional training as requested or deemed necessary
• Ability to attend in-person regulatory meetings with clients
• Ability to evaluate laws and regulations and prioritize content for policy and procedure updates
• Ability to interpret laws and regulations and communicate them to management and line personnel
• Ability to research and investigate regulatory issues related to operating subsidiaries and businesses
• Ability to identify risks and recommend regulatory compliance controls
• Ability to manage multiple projects and duties simultaneously and work collaboratively in a nonhierarchical department structure
• Ability to interface with management, internal and external clients, and subject matter experts
• Strong writing skills and extensive policy and procedure writing experience required
• Strong verbal communication skills
• Strong collaborative, analytical, problem-solving, and decision-making skills
• Meticulous organizational skills and attention to detail
• Strong PowerPoint and advanced Excel capabilities preferred

Core Competencies

Demonstrates extensive knowledge of Medicaid Managed Care regulations and program integrity, with strong capabilities in fraud prevention, data analysis, and compliance management. Proven experience in leading investigations and collaborating with government agencies to ensure program effectiveness and integrity.

Highest-signal resume keywords

• Medicaid Managed Care Compliance
• Fraud Prevention and Investigation
• Data Analysis and Utilization Review
• Policy and Procedure Development
• Senior Leadership Experience

Hard Skills

• Program Integrity Management
• Regulatory Compliance
• Utilization Management
• Advanced Data Analysis
• Policy Writing
• Risk Assessment
• Project Management
• Health Care Delivery Knowledge
• Metrics Assessment
• Investigative Research

Soft Skills

• Strong Verbal Communication
• Analytical Problem-Solving
• Decision-Making
• Collaboration
• Organizational Skills

Industry Keywords

• Fraud, Waste, and Abuse Prevention
• Iowa Medicaid Rules
• CMS Regulations
• Health Plan Management
• Public Health Program Functions

Tools & Technologies

• Excel
• PowerPoint