Program Integrity Manager

The Program Integrity Manager serves as a key leader supporting Medicaid Program Integrity, Payment Integrity, and Special Investigations Unit (SIU) activities for the New Jersey Medicaid Health Plan. This role is responsible for ensuring compliance with state and federal requirements, supporting fraud, waste, and abuse (FWA) prevention efforts, overseeing regulatory and contractual obligations, coordinating reporting and audit activities, and partnering with internal and external stakeholders to promote operational effectiveness and program integrity. The position works closely with health plan leadership, Compliance, Legal, Clinical, Provider Relations, Analytics, Operations, SIU, and external vendors to drive strategic initiatives, lead cross-functional projects, facilitate meetings and workgroups, and identify opportunities for innovation and process improvement. The Program Integrity Manager must be able to influence stakeholders, obtain buy-in, present to diverse audiences, and lead initiatives from concept through implementation.

Responsibilities

• Ensure compliance with state and federal requirements for Medicaid Program Integrity, Payment Integrity, and SIU activities.
• Support fraud, waste, and abuse (FWA) prevention efforts.
• Oversee regulatory and contractual obligations.
• Coordinate reporting and audit activities.
• Partner with internal and external stakeholders to promote operational effectiveness and program integrity.
• Drive strategic initiatives and lead cross-functional projects.
• Facilitate meetings and workgroups.
• Identify opportunities for innovation and process improvement.
• Influence stakeholders, obtain buy-in, and present to diverse audiences.
• Lead initiatives from concept through implementation.

Requirements

• 5+ years of experience in Program Integrity, Payment Integrity, SIU, Healthcare Compliance, FWA, Claims Operations, Healthcare Operations, or a related field, including experience in a leadership, supervisory, management, or project lead capacity.
• Knowledge of healthcare regulatory and compliance requirements.
• Strong analytical, organizational, communication, and problem-solving skills.
• Demonstrated experience leading projects, initiatives, meetings, and cross-functional workgroups.
• Experience partnering with multiple business areas and external stakeholders to achieve business objectives.
• Strong presentation and facilitation skills with the ability to communicate effectively to leadership and stakeholder groups.
• Proven ability to drive process improvements, lead ideation efforts, gain stakeholder buy-in, and influence decision-making.
• Ability to manage multiple priorities and work effectively in a collaborative environment.

Qualifications

• Bachelor's degree or equivalent combination of education and experience.
• Experience supporting Medicaid managed care programs (preferred).
• Experience with regulatory reporting, audits, compliance initiatives, or operational oversight activities (preferred).
• Experience working with SIU investigations, fraud prevention programs, vendor management, or payment integrity operations (preferred).
• Knowledge of healthcare claims, provider reimbursement, payment accuracy, and program integrity practices (preferred).
• Project management experience leading strategic or operational initiatives across multiple business partners (preferred).

Schedule

• Full time, 40 anticipated weekly hours.
• Hybrid work environment: compliance with hybrid work policy required, working onsite three days a week if living near a suitable work location.

Pay

The typical pay range for this role is $54,300.00 - $145,860.00 annually. This position is also eligible for a CVS Health bonus, commission, or short-term incentive program in addition to the base pay range.

Benefits

• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs.
• Additional resources based on eligibility.