Director of Program Integrity-5

Job Type: Full Time

Job Category: IT

Job Description

Role - Director of Program Integrity
Location – Dallas, TX
FTE

This role is for a Manager or Director of Payment Integrity / Audit & Recovery within a Managed Care Health Plan (Texas Medicaid focus) — specifically someone who ensures the organization prevents overpayments, fraud, waste, and abuse in claims and payment systems, while improving operational efficiency and compliance.

Here’s a breakdown to help you identify the ideal candidate profile

Role Overview:

This professional will lead a payment integrity team responsible for ensuring accurate claim payments, developing audit strategies (data mining, clinical record review, bill audit recovery), and driving process improvement. They’ll also oversee department goals, budgets, compliance, and staff performance — ensuring alignment with Texas Medicaid and Managed Care regulations.

Core Focus Areas:

Payment Integrity & Audit Management:

Prevents overpayments, fraud, waste, and abuse.
Leads data mining, claims audit, and recovery initiatives.
Works on payment accuracy and root cause correction.

Operational Excellence:

Improves workflows, job design, and efficiency.
Develops and implements strategic department goals and budgets.

Regulatory & Compliance Oversight:

Ensures adherence to Texas Medicaid (STAR, STAR Kids, CHIP), NCQA, and Uniform Managed Care Contract/Manual.
Maintains up-to-date knowledge of Medicaid laws, coding (ICD-10, CPT/HCPC), and compliance requirements.

Leadership & People Management:

Supervises, trains, and mentors staff.
Drives accountability and performance.
Builds interdepartmental and external relationships.

Strategic Planning:

Designs data-driven audit strategies.
Works cross-functionally with finance, operations, and compliance teams.
Provides analytical insights to executive leadership.

Ideal Candidate Profile:

Category	Requirements
Experience	8+ years in Payment Integrity Audit & Recovery, with at least 5 years in management
Domain Expertise	Must have Texas Medicaid or Managed Care Health Plan background (payer-side, not provider-side)
Technical Knowledge	ICD-10, CPT/HCPC coding, audit and recovery methodologies, compliance frameworks
Certifications	Project Management (PMP) or Six Sigma — strongly preferred
Soft Skills	Strategic thinker, strong communicator, problem solver, conflict resolution, leadership
Tools	Proficiency in Microsoft Office, data analytics tools, audit software, and workflow systems

Do NOT target candidates who:

Work primarily on revenue cycle management (RCM) or provider-side billing.
Have experience only in hospital/healthcare system reimbursement — the client wants payer-side health plan experience.
Lack familiarity with Texas Medicaid or managed care audit processes.

Target Candidate Examples:

Payment Integrity Manager / Director at a health plan (e.g., Molina, Amerigroup, Superior HealthPlan, UnitedHealthcare Community Plan).
Audit & Recovery Manager in a Medicaid Managed Care setting.
Program Integrity Manager or Claims Audit Lead with hands-on experience in data mining and overpayment prevention

Required Skills

Program Manager Programmer Analyst

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