What are the responsibilities and job description for the Director of Program Integrity - Healthcare position at Rinvio Recruitment?
**Director of Program Integrity Job Summary:**
The Director of Program Integrity is in charge of leading the Program Integrity department.
This role focuses on making sure claims are correctly edited, preventing fraud, waste, and abuse (FWA), and ensuring payments are accurate. The goal is to achieve high operational standards, save costs, and follow state and federal rules.
**Job Responsibilities:**
1. Look at job designs, work processes, and workflows in the department. Make changes to improve effectiveness and efficiency, supporting PCHP’s overall goals.
2. Keep updated on new developments in the field by attending workshops, reading journals, and being active in professional groups. Use this knowledge in daily work.
3. Understand the rules and regulations that affect the department. Create internal controls to ensure compliance with laws and requirements. Seek help when necessary for clarity.
4. Prepare and monitor the annual budget to ensure the department has enough funds to meet its goals.
5. Create and adjust annual goals for the department that align with PCHP’s mission.
6. Hire, train, schedule, motivate, supervise, and evaluate employees. Make recommendations about their performance, including any disciplinary actions if necessary. Ensure employees have opportunities to learn and grow.
**Skills Needed:**
- Excellent speaking and writing skills to communicate effectively with different people.
- Ability to coach others and influence for better results.
- Good interpersonal skills to resolve conflicts and build effective relationships within and outside the organization. - Strategic thinking skills to plan for the future and achieve goals.
- Ability to handle challenging situations that involve different interests and large groups.
- Strong time management and organizational skills to manage multiple tasks effectively.
- Good analytical and problem-solving skills.
- Knowledge of Texas Medicaid programs, quality assurance standards, and relevant guidelines.
- Strong business understanding.
- Proficient in Microsoft Office and general computer skills.
**Qualifications:**
- Five (5) years of management experience
- Required. - Eight (8) years of work experience in Payment Integrity Audit and Recovery is strongly preferred.
- Two (2) years of experience in a Managed Care health plan or a state agency
- Required. - Knowledge of ICD-10 and CPT/HCPC coding
- Required. - Eight (8) years of relevant work experience in Texas Medicaid or Medicaid Managed Care can replace a bachelor’s degree.
- Five (5) years of experience specifically in Texas Medicaid or Managed Care is strongly preferred.
- Project management or Six Sigma certification is strongly preferred.
