Program Integrity Manager - New Mexico

At UnitedHealthcare, we’re simplifying the health care experience, creating healthier communities and removing barriers to quality care. The work you do here impacts the lives of millions of people for the better. Come build the health care system of tomorrow, making it more responsive, affordable and equitable. Ready to make a difference? Join us to start Caring. Connecting. Growing together.

UnitedHealthcare Community & State, part of the UnitedHealth Group family of companies, is looking for an experienced Health Plan Program Integrity / Fraud, Waste and Abuse compliance consultant to join our dynamic Compliance team. The Program Integrity Manager is an individual contributor role responsible for fraud, waste and abuse and specific research leading to best practice policy implementation and vendor/subcontractor monitoring to drive problem/process resolution for the New Mexico Medicaid health plan.

If you are located in New Mexico, you will have the flexibility to work remotely* as you take on some tough challenges.

Primary Responsibilities:

• Works to ensure that internal processes are executed, especially related to intersegment responsibilities, for fraud, waste, and abuse (FWA) vendors’ instances of health care FWA by medical profession or insured member
• Acts as FWA subject matter expert for Federal and local FWA regulations and subsequent regulatory policy and process implementation
• Keeping apprised of current, proposed, and new federal and state regulations / guidelines
• Ensures that changes in requirements are included in education and carried out by required audiences
• Serves as health plan FWA trainer. Coordinates and supports implementation of FWA training and educational programs with the appropriate business areas and vendors
• As necessary, gather and analyze all information and documents related to a FWA investigation
• Acts as health plan FWA vendor liaison, i.e., conducts reviews on policies to make sure they are compliant; ensures that vendor processes are executed appropriately; that timelines are met per regulatory fulfillment; sets boundaries for vendors so that accountabilities are clear
• Serves as regulatory FWA liaison to the regulatory entities and internally to key FWA organizational partners, including participation in meetings with regulators
• Develops and maintains fraud-related policies, e.g., documents the education and hand-offs for the health plan from functional teams as required to meet contractual obligations
• Oversees and ensures all required FWA regulatory reporting meets regulatory expectations
• Ensures procedures are established to support timely communication and education regarding the fraud program
• Ensures that procedures are in place to review and report possible violations in accordance with the reporting requirements as outlined in the FWA Plan. Reviews vendors to make sure that all aspects of FWA are managed and policies are developed where gaps are identified

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• 2+ years of experience in a FWA, investigations, regulatory, compliance, or related role
• 2+ years of experience working in a government, health care, managed care, insurance or related environment
• Experience translating highly complex concepts in ways that can be understood by a variety of audiences
• Experience identifying root cause issues and ensuring appropriate corrective action
• Intermediate or higher proficiency using MS Word, MS Excel and MS PowerPoint
• Currently reside within the state of New Mexico

Preferred Qualifications:

• Experience auditing medical billing and coding
• Demonstrated ability to manage multiple projects and multiple relationships across the matrix
• Demonstrated ability to stay organized and use time management skills
• Demonstrated ability to work effectively and congenially with employees at all levels
• Proven excellent written and verbal English communication skills

• All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.