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Program Integrity Manager (Must be in Kansas state - Remote) at CVS Health

Program Integrity Manager (Must be in Kansas state - Remote)

CVS Health Work from Home/Remote Full-Time
Job Description

The Program Integrity manager oversees health plan activities related to program integrity including regulatory reporting, coordinating interdepartmental program integrity initiatives, vendor oversight of fraud waste and abuse (FWA) activity, and identifying services at risk for FWA. Responsible for compliance with state and federal regulations mandating the reporting of corporate fraud related activities and the preparation of the corporate Anti-Fraud Plan. Serve as single point of contact for Kansas Medicaid programs for all program integrity related issues. Manage, develop, and submit all program integrity related regulatory reports.? ? Fundamental Components & Physical Requirements include but are not limited to:? • Ability to comprehend and implement Medicaid regulations and contracts.• Comprehensive knowledge and application of 42 CFR § 438.608• Coordinate with?department leaders to full fill the requirements of the program integrity unit• Comply with all program integrity related requests, both internal and external, and meet request timeliness • Ability to detect, investigate, prevent, and report issues of suspected fraud, waste, or abuse.• Accurately document all activity?and communications related to FWA investigations using a proprietary case tracking system. • Ability to handle and maintain confidential and sensitive information pertaining to providers.• Creation and review of?policy, procedures,?desktops and?health plan addendums • Maintain the Annual Fraud Plan, Risk?Assessments and Work Plan?including any health plan addendums • Collaboration with plan?Compliance• Liaison with KDHE-DHCF, MFCU and other state law enforcement• Audit preparation • State reporting oversight and?submission • Oversight and?Coordination of Vendor FWA activities• Draft requests for proposal on?new/rebidding of contracts • Annual plan FWA training • Readiness Reviews

Pay Range

The typical pay range for this role is:

Minimum: 43,700

Maximum: 97,400

Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.

Required Qualifications

- Located in the Kansas area.- Minimum three years in healthcare field working in fraud, waste and abuse investigations and audits.- Strong analytical and research skills.- Proficient in researching information and identifyinginformation resources.- Strong verbal and written communication skills.- Strong customer service skills. - Ability to interact with different groups of people at different levels and provide assistance on a timely basis.- Proficiency in Word, Excel, MS Outlook products, Database search tools, and use in the Intranet/Internet to research information.- Ability to utilize company systems to obtain relevant electronic documentation

Preferred Qualifications

- One year experience with Program Integrity. - Credentials such as a certification from the Association of Certified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI)- Billing and Coding certifications such as CPC (AAPC) and/or CCS (AHIMA)- Knowledge of CPT/HCPCS/ICD10 coding- Experience with Medicaid/Medicare - Experience with Behavioral Health - Knowledge of Aetna's Medicaid policies and procedures is a plus


- Bachelor's degree or Associates' degree with additional three years of healthcare fraud investigation experience.

Business Overview

Bring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

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