Program Integrity Director

Job description

**This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Program Integrity Director based in the United States.** This executive-level role will define and lead an enterprise-wide Program Integrity strategy focused on Medicare and other federal healthcare programs. The position will shape long-term capabilities across fraud, waste, and abuse prevention, payment integrity, medical review, provider audits, analytics, and compliance operations. As a strategic subject matter expert, you will identify opportunities to strengthen existing programs, expand services, and improve operational performance. You will translate emerging CMS priorities, regulatory developments, and technological advances into actionable strategies and investment plans. Working across clinical, operational, technical, compliance, analytics, and business development teams, you will drive innovation and measurable outcomes. The role offers an opportunity to influence major federal healthcare initiatives while helping build scalable, future-ready Program Integrity capabilities. ### Accountabilities: - Develop and maintain the enterprise Program Integrity strategy, roadmap, future-state vision, and multi-year execution plans across Medicare operations. - Identify opportunities to expand Program Integrity services, increase contract value, support new business opportunities, and develop business cases for additional federal healthcare work. - Recommend investments in technology, staffing, partnerships, automation, AI, analytics, medical review modernization, provider audits, payment integrity, and other strategic capabilities. - Establish performance metrics and dashboards covering financial impact, quality, operational effectiveness, customer satisfaction, compliance, and return on investment. - Monitor emerging CMS priorities, regulatory changes, fraud trends, payment integrity initiatives, and policy developments to identify risks and opportunities. - Build strong relationships with senior executives, CMS leaders, government stakeholders, industry partners, vendors, and professional organizations. - Support strategic customer and business development activities through executive presentations, thought leadership materials, concept papers, value propositions, and strategic discussions. - Lead cross-functional teams and collaborate with Operations, Technology, Data & Analytics, Clinical Services, Quality, Continuous Improvement, Customer Relations, and Business Development. - Evaluate and oversee innovation initiatives and pilot programs from concept through implementation, establishing governance models, timelines, success measures, and operational plans. - Serve as the primary internal consultant and thought leader for Program Integrity strategy while championing continuous improvement and innovation. ### Requirements: - Bachelor’s degree in Business, Healthcare Administration, Public Administration, Data Analytics, Nursing, Health Information Management, or a related field, or equivalent professional experience. - At least 10 years of progressive experience in healthcare, Medicare, Medicaid, federal health programs, audit, compliance, or Program Integrity, including at least 7 years in leadership or initiative-leadership roles. - Demonstrated experience developing enterprise strategies and translating them into practical operational execution plans. - Strong knowledge of Medicare operations, CMS programs, federal healthcare contracting, Program Integrity, payment integrity, medical review, audit, compliance, or related functions. - Proven ability to present complex strategies and recommendations to senior executives, government stakeholders, and other external audiences. - Exceptional strategic planning, communication, relationship management, analytical, critical-thinking, and problem-solving skills. - Experience with Medicare Administrative Contractor, SMRC, UPIC, RAC, or other CMS Program Integrity programs is preferred. - Experience leading Program Integrity activities within a federal or state government environment, including fraud, waste, and abuse prevention, investigations, audits, compliance, or payment integrity, is preferred. - Familiarity with AI, predictive analytics, fraud detection technologies, healthcare data platforms, or automation is preferred. - Experience supporting federal business development, growth initiatives, or contract expansion is a plus. - Master’s degree such as an MBA, MHA, MPH, or related field and certifications in Lean, Six Sigma, Project Management, or Change Management are preferred. - Demonstrated ability to operate as a functional expert, introduce innovative solutions, work independently, manage complexity, and maintain strong attention to detail. - Ability to work effectively in a remote environment, communicate clearly, solve problems, and collaborate across diverse functions. - Must be able to work from within one of the 50 U.S. states or the District of Columbia. Periodic travel to conferences and customer or organizational locations is required. - Certain assignments may require successful completion of government background screening, compliance with applicable federal requirements, and eligibility for a government-issued identification card. ### Benefits: - Annual salary range of $104,831.40–$172,420.71, with actual compensation determined by factors including geographic location, internal equity, knowledge, skills, and experience. - Incentive plan and lifestyle benefit. - Health, dental, and vision insurance. - Voluntary insurance plans, health savings accounts, and flexible spending accounts. - 401(k) plan with company match. - Company-paid life insurance. - Education assistance and online learning opportunities. - Paid sick leave, paid holidays, and increasing PTO accrual. - Medical, parental, and disability leave. - Retiree benefits and employee assistance program. - Financial and health wellness benefits. - Remote/work-from-home eligibility. - Casual dress and an office environment designed to support collaboration. - Workers’ compensation coverage.