Program Integrity Manager reside in Des Moines, IA

Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide.

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Denta Quest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.

Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work. Our team members and leaders are expected to foster connection and teamwork by being present in the office at least 2 days per week in Des Moines, IA.

Reporting to the Director of Regulatory Compliance & Program Integrity, the Iowa Program Integrity Manager is accountable for leading and overseeing a Medicaid Managed Care program integrity operation, providing strategic direction, leadership, and oversight of special investigations and activities to prevent and address fraud, waste, and abuse. This role collaborates closely with state Medicaid administrators, CMS, federal and state law enforcement, and managed care organizations to develop, implement, and continuously improve program integrity strategies, policies, and systems.

The position requires senior-level experience in healthcare delivery and program integrity, comprehensive knowledge of Medicaid laws and regulations, and the ability to analyze data and trends to drive effective oversight and enforcement actions. Serving as the primary liaison between Sun Life Denta Quest and our client at Iowa Health and Human Services, the Program Integrity Manager is based near Des Moines, Iowa, works full time, and is responsible for ensuring transparency, accountability, and safeguarding the integrity of Medicaid programs through full access to claims, processing data, and investigative resources.

• Provide leadership and strategic oversight of Denta Quest Program Integrity and Special Investigations Unit (SIU) activities.
• Participate in Fraud, Prevention, and Recovery operations and oversight activities to prevent, detect and investigate fraud, waste, and abuse.
• Collaborate with Clinical Quality Management to improve fraud, waste, and abuse prevention activities.
• Develop, implement, and continuously improve program integrity strategies aligned with Iowa Medicaid rules and regulations.
• Perform advanced data analysis and drill-down utilization reviews to identify under- and over-utilization trends and program risks.
• Collaborate with state Medicaid agencies, CMS, managed care organizations, and state and federal law enforcement.
• Partner with Dental Directors to ensure investigative decisions are clinically sound,…