Director of Program Integrity

***HM looking only considering candidates who actually have payment integrity, rather than revenue recovery experience. Payer-focused on preventing overpayments and preventing fraud, waste, and abuse. Health Plan experience, not healthcare system experience.***

***Will have to be onsite at least SIX DAYS a month.***

The Director of Program Integrity provides leadership oversight and directs the operations for the Program Integrity department and associated functions with focus on claims editing, fraud, waste, and abuse (FWA) prevention, and payment accuracy. Accountable for supporting Parkland Community Health Plan’s (PCHP) commitment to operational excellence, cost containment, and adherence to state and federal requirements.

Job Responsibilities:

1. Identifies and analyzes the design of jobs, work processes, work flows, etc. for the area and

implements appropriate changes to improve effectiveness, productivity, and efficiency that

support the overall goals of PCHP.

2. Stays abreast of the latest developments, advancements, and trends in the field by attending

seminars/workshops, reading professional journals, actively participating in professional

organizations, and/or maintaining certification or licensure. Integrates knowledge gained into

current work practices.

3. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the

area. Develops effective internal controls designed to promote adherence with applicable laws,

accreditation agency requirements, and customer requirements. Seeks advice and guidance as

needed to ensure proper understanding.

4. Develops and monitors annual budgets that ensure the department has the necessary funds to

carry out the goals and objectives that have been established for the department.

5. Develops, implements, monitors, and revises annual goals and objectives for the department that

support the missions and objectives of PCHP.

6. Selects, trains, schedules, motivates, supervises, and evaluates employees making

recommendations for disciplinary actions up to and including termination, to ensure maximum

utilization of individual and group capabilities. Ensures that assigned employees receive

opportunities to further their knowledge.

Skills or Special Abilities:

• Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines and with a variety of constituents as well as the ability to articulate complex information in understandable terms.
• Demonstrated ability to coach and influence for results.
• Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships with diverse groups across and beyond the organization.
• Strategic thinking and long-range planning skills with the ability to lead major organizational initiatives, accomplish results, and achieve measurable outcomes or goals.
• Ability to work in challenging situations involving competing interests, and high level interdisciplinary groups.
• Excellent time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.
• Strong analytical and problem-solving skills.
• Knowledge of Texas Medicaid (STAR, STAR Kids/CHIP) program, National Committee for Quality
• Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.
• Sound business acumen.
• Proficient Microsoft Office and computer skills.

Benefits:

• Medical
• Dental
• Vision
• Life Insurance
• Disability Insurance
• Flexible Spending Accounts
• And more!

Qualification/Experience Requirement:

• Five (5) years of management experience - Required.
• Eight (8) years of experience in Payment Integrity Audit and Recovery with knowledge of audit strategies such as Data Mining, Clinical Medical Record Review, and Bill Audit Recovery/Program Integrity experience - Strongly Preferred.
• 2 years of experience in a Managed Care health plan or state agency - Required.
• Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology - Required.
• Eight (8) years of experience in a comparable position working in Texas Medicaid or Medicaid Managed Care may be considered in lieu of a bachelor’s degree.
• 5 Years of Texas Medicaid, Managed Care Health Plan or State agency experience - Required. ***Please list the types of Medicaid Health Plans candidate is familiar with.***

Certification/Registration/Licensure:

• Project management or Six Sigma certification - Strongly Preferred.

“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”