Program Manager
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Administrative Program Integrity ReviewsDirect administrative program integrity reviews involving potential fraud, waste, abuse, improper payments, control weaknesses, and other program integrity risks affecting Federal health benefits programs.
Lead oversight of administrative reviews by evaluating program documentation, audit findings, referral information, claims and payment data, and other relevant materials to recommend corrective actions, recoveries, disallowances, sanctions-implementation steps, or other administrative remedy options.
Oversee health insurance carriers' compliance with contractual and regulatory requirements by directing carrier compliance reviews, validating corrective actions, and resolving program integrity findings through appropriate administrative processes.
Analyze program integrity trends, claims data, audit results, carrier submissions, and risk indicators to identify vulnerabilities, improper payment risks, control weaknesses, and opportunities to strengthen fraud prevention and detection efforts.
Coordinate administrative review, referral, corrective-action, compliance, and contract-remedy activities with Offices of Inspector General, legal counsel, contracting officials, program offices, carriers, health care organizations, and other oversight partners.
Develop policies, procedures, documentation standards, referral protocols, corrective-action processes, and performance measures that improve health insurance program integrity, accountability, and administrative oversight.
Supervise a multidisciplinary workforce responsible for administrative program integrity reviews, carrier compliance oversight, audit resolution, payment integrity, corrective-action monitoring, referral coordination, and contract-remedy support.
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