Director, Medicaid Program Integrity - Remote

About the role

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth.

The Medicaid Program Integrity Leader is responsible for developing, implementing, and overseeing Optum's Medicaid program integrity strategies to assist State Agencies compliance with federal and state Medicaid regulations while preventing, detecting, and addressing fraud, waste, and abuse (FWA). This leader drives operational excellence through data analytics, audits, product insight, and collaboration with internal and external stakeholders. The role balances regulatory compliance, financial stewardship, and member/provider experience to safeguard Medicaid program resources.

You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. For all hires in the Minneapolis or Washington, D.C. area, you will be required to work in the office a minimum of four days per week.

Responsibilities

Strategic Leadership

• Develop and execute the organization's Medicaid Program Integrity strategy
• Establish goals, KPIs, and performance metrics aligned with organizational objectives
• Lead program integrity operations across pre-payment, post-payment, and support development of new business operations
• Serve as a subject matter expert on Medicaid integrity requirements and emerging regulatory guidance

Compliance & Regulatory Oversight

• Ensure compliance with CMS, state Medicaid agencies, Office of Inspector General (OIG), and contractual requirements
• Oversee preparation for audits, investigations, and regulatory reviews
• Interpret federal and state regulations and translate them into operational policies and procedures
• Maintain effective controls to support compliance and risk mitigation
• Present findings, risks, and recommendations to executive leadership and governing committees

Data Analytics & Risk Management

• Leverage advanced analytics to identify billing anomalies, emerging fraud schemes, and utilization trends
• Establish predictive and retrospective monitoring programs
• Utilize data-driven approaches to prioritize investigations and maximize recoveries
• Monitor program integrity performance through dashboards and executive reporting

Financial Stewardship

• Manage program integrity budgets and resources
• Identify opportunities for cost avoidance, recoveries, and operational efficiencies
• Quantify savings and return on investment for program integrity initiatives
• Report financial outcomes to executive leadership

Team Leadership

• Lead multidisciplinary teams including data analysts, developers, business analysts
• Foster a culture of accountability, collaboration, and continuous improvement
• Develop succession plans and talent management strategies
• Mentor leaders and staff to strengthen organizational capabilities

Required Qualifications

• 5+ years of healthcare, Medicaid, compliance, audit, investigations, or program integrity experience
• 5+ years of leadership experience managing teams and complex programs
• 5+ years of experience with fraud, waste, and abuse investigations and audit programs
• 2+ years of experience with Medicaid managed care regulations, CMS guidance, and program integrity requirements
• 2+ years of experience in data analytics and reporting capabilities
• Excellent communication, executive presentation, and stakeholder management skills
• Ability to travel up to 25%

Preferred Qualifications

• Certified Fraud Examiner (CFE), Certified Compliance & Ethics Professional (CCEP), Certified Internal Auditor (CIA), or similar certification
• Experience with managed care organizations (MCOs), state Medicaid agencies, or healthcare payers
• Knowledge of advanced analytics, predictive modeling, and AI-enabled fraud detection

Key Competencies

• Strategic Leadership
• Regulatory Expertise
• Fraud, Waste & Abuse Prevention
• Healthcare Analytics
• Risk Management
• Financial Acumen
• Executive Communication
• Change Management
• Team Development
• Stakeholder Engagement

Pay

The salary for this role will range from $134,600 - $230,800 annually based on full-time employment. We comply with all minimum wage laws as applicable.