Sr. Director, Program Integrity

Benefits

Additional Information

It's fun to work in a company where people truly BELIEVE in what they're doing! We're committed to bringing passion and customer focus to the business. Public Partnerships LLC supports individuals with disabilities or chronic illnesses and aging adults, to remain in their homes and communities and "self" direct their own long-term home care. Our role as the nation's largest and most experienced Financial Management Service provider is to assist those eligible Medicaid recipients to choose and pay for their own support workers and services within their state-approved personalized budget. We are appointed by states and managed healthcare organizations to better serve more of their residents and members requiring long-term care and ensure the efficient use of taxpayer funded services. Our culture attracts and rewards people who are results-oriented and strive to exceed customer expectations. We desire motivated candidates who are excited to join our fast-paced, entrepreneurial environment, and who want to make a difference in helping transform the lives of the consumers we serve. (learn more at www.pplfirst.com ). The Senior Director, Program Integrity provides strategic and operational leadership over the organization's enterprise‑wide fraud, waste, and abuse (FWA) program, ensuring regulatory compliance, risk mitigation, and program effectiveness across all states. Reporting to the Vice President, Compliance, this role serves as the primary senior liaison with regulatory and law enforcement agencies, including OMIG and MFCUs, and oversees fraud detection, investigation, audit readiness, and corrective action management. The Senior Director establishes governance frameworks, drives data‑informed integrity initiatives, standardizes processes across markets and health plan partners, and leads continuous improvement efforts to identify emerging risks, strengthen controls, and promote a culture of accountability and compliance. Duties & Responsibilities: Regulatory & External Relationship Management Map, maintain, and continuously update a comprehensive inventory of all relevant state program integrity agencies, including MFCUs and state Medicaid integrity units Serve as the primary point of contact with regulators, including OMIG, MFCUs, and other law enforcement and oversight entities Establish and maintain strong, credible relationships with regulatory partners to support collaboration, transparency, and trust Collaborate with Health Plans in fraud, waste and abuse investigation and referral processes. Oversee and standardize fraud, waste, and abuse referral processes across all states, ensuring timeliness, completeness, and regulatory compliance Monitor evolving regulatory expectations and ensure program alignment with federal and state requirements Program Integrity Strategy & Governance Design and implement an enterprise-wide program integrity framework aligned with organizational risk, regulatory expectations, and industry best practices Develop and maintain a centralized fraud risk register, including risk identification, scoring, mitigation strategies, and ownership Establish governance structures for fraud oversight, including reporting to executive leadership and compliance committees Catalogue and continuously update fraud prevention and detection best practices across the organization Fraud Detection, Investigation & Oversight Oversee fraud investigation and auditing Ensure effective intake, triage, investigation, and resolution of suspected fraud, waste, and abuse cases Provide strategic direction and oversight for complex, high-risk investigations Ensure proper documentation, case management, and audit readiness Monitor and ensure execution of corrective action plans (CAPs) resulting from investigations, audits, and regulatory findings Analytics, Reporting & Performance Measurement Oversee the design, implementation, and continuous enhancement of program integrity dashboards and reporting tools Partner with data/analytics teams to develop predictive and retrospective fraud detection methodologies Establish KPIs and performance metrics for fraud detection, investigation efficiency, and prevention impact Quantify and report cost savings and cost avoidance resulting from fraud prevention and detection initiatives Leverage data mining and trend analysis to identify emerging fraud schemes and risk areas Program Development & Continuous Improvement Lead the development and execution of fraud prevention initiatives, including pre-payment controls and policy enhancements Identify systemic vulnerabilities and implement proactive interventions to mitigate risk Drive continuous improvement through benchmarking, regulatory insights, and industry collaboration Support training and awareness programs related to fraud, waste, and abuse Required Skills: Excellent knowledge of relevant laws, regulations and industry standards CDPAP and Medicaid experience Experience managing relations