Program Integrity Manager
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What you'll do
- Ensure compliance with state and federal requirements
- Support fraud, waste, and abuse (FWA) prevention efforts
- Oversee regulatory and contractual obligations
- Coordinate reporting and audit activities
- Partner with internal and external stakeholders to promote operational effectiveness and program integrity
What they're looking for
- 5+ years experience in Program Integrity, Payment Integrity, Special Investigations, Healthcare Compliance, Fraud, Waste and Abuse (FWA), Claims Operations, Healthcare Operations, or a related field.
- Knowledge of healthcare regulatory and compliance requirements.
- Strong analytical, organizational, communication, and problem-solving skills.
- Ability to manage multiple priorities and work effectively in a collaborative environment.
- Experience building relationships and working with cross-functional teams and external stakeholders.
Nice to have
- Experience supporting Medicaid managed care programs.
- Experience with regulatory reporting, audits, compliance initiatives, or operational oversight activities.
- Experience working with SIU investigations, fraud prevention programs, vendor management, or payment integrity operations.
- Knowledge of healthcare claims, provider reimbursement, payment accuracy, and program integrity practices.
Summarised by NextRaise from the employer’s description, which follows in full below.
Full description from employer
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Position Summary
The Program Integrity Manager serves as a key leader supporting Program Integrity, Payment Integrity, and Special Investigations Unit (SIU) activities. This role is responsible for ensuring compliance with state and federal requirements, supporting fraud, waste, and abuse (FWA) prevention efforts, overseeing regulatory and contractual obligations, coordinating reporting and audit activities, and partnering with internal and external stakeholders to promote operational effectiveness and program integrity. The position works closely with health plan leadership, compliance, SIU, payment integrity vendors, and operational teams to support initiatives that improve performance, strengthen oversight, and ensure compliance with applicable requirements.
Required Qualifications
5+ years experience in Program Integrity, Payment Integrity, Special Investigations, Healthcare Compliance, Fraud, Waste and Abuse (FWA), Claims Operations, Healthcare Operations, or a related field.
Knowledge of healthcare regulatory and compliance requirements.
Strong analytical, organizational, communication, and problem-solving skills.
Ability to manage multiple priorities and work effectively in a collaborative environment.
Experience building relationships and working with cross-functional teams and external stakeholders.
Preferred Qualifications
Experience supporting Medicaid managed care programs.
Experience with regulatory reporting, audits, compliance initiatives, or operational oversight activities.
Experience working with SIU investigations, fraud prevention programs, vendor management, or payment integrity operations.
Knowledge of healthcare claims, provider reimbursement, payment accuracy, and program integrity practices.
Education
Bachelor's degree or equivalent combination of education and experience.
**We support a hybrid work environment. If selected and you live near a suitable work location, you may be expected to comply with the hybrid work policy. Under the policy, all hires for in-scope populations should be placed into a hybrid or office-based location, working onsite three days a week.
Aetna Service Operations office/hub locations will be discussed with the selected candidate.
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$66,330.00 - $145,860.00This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Company
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