Program Integrity Contract Lead

The Program Integrity (PI) Contract Lead is an important member of the leadership team and works directly with Program Integrity Leadership, the Compliance Officer, and the Compliance Committee. This position requires a strong understanding of the VA Community Care Network (CCN) program, including, but not limited to, federal health care program requirements, Executive Order 12549, Federal Acquisition Regulation (FAR) Part 3, the Federal False Claims Act, and applicable state and federal laws governing program integrity and compliance.

The PI Contract Lead analyzes and evaluates the effectiveness of existing business processes and develops sustainable, repeatable, and measurable process improvements. You will participate in and influence departmental and cross-functional strategy discussions, recommending changes needed to maintain compliance with contractual obligations and regulatory requirements. You will address issues of varied scope and complexity, ranging from moderate to significant.

The PI Contract Lead works collaboratively with key stakeholders to provide consultative support, internal briefings, training, and participation in integrated care planning, as needed. You will partner with stakeholders to identify, develop, and implement corrective actions. Responsibilities include performing root cause analyses, escalating significant concerns to leadership, and recommending functional strategies to address identified risks or gaps. Decisions may involve resource allocation, operational approach, tactical execution, and department-level initiatives.

Administrative responsibilities include, but are not limited to, preparing and maintaining Contract Data Requirements List (CDRL) reports; managing the Program Integrity library, including letters, job aids, and process flow documentation; reviewing associate documentation and tools; analyzing data findings; and briefing the team on key results and recommendations. The PI Contract Lead also provides support to data and technology teams in the development of business and financial models.

35% Translate contract requirements into business processes, workflows, controls, procedures, and operational requirements. Develop implementation workplans, milestones, dependencies, risks and readiness criteria for projects

25% Identify operational gaps and recommend process changes necessary to meet contractual requirements. Support development of standard operating procedures, desk level procedures, workflows, job aids and training materials.

15% Establish and maintain an ongoing contract monitoring framework to ensure continued compliance with contractual requirements. Monitor contract performance, service level agreements, key performance indicators, deliverables, milestones, and operational commitments.

15% Apply Lean, Six Sigma, root cause analysis and other process improvement methodologies to improve operational and contract performance.

10% Conduct routine reviews of contract requirements to ensure operational processes remain aligned with current contractual obligations.

This role description in no way states or implies that the key accountabilities above are the only ones being performed by the individual(s) with this role description. The individual(s) may be called upon and required to follow other instructions or perform other duties and tasks requested by his or her supervisor, consistent with the purpose of the position, department and/or company objectives.

• 5 or more years of Program Integrity and/or Payment Integrity experience

• 2 or more years of project management (Ideally in implementing large contracts) experience

• Must have ONE of the following ant-fraud degrees, designations, and/or certifications :

• Registered Nurse/Bachelor of Science in Nursing (RN/BSN)
• Certified Profession Coder (CPC)
• Certified Coding Specialist (CCS)
• Certified Clinical Documentation Specialist (CCDS)
• Certification in Healthcare Compliance (CHC)
• Health Care Anti-Fraud Associate (HCAFA)
• Accredited Health Care Fraud Investigator (AHFI)
• Certified Fraud Examiner (CFE)
• Juris Doctorate (JD)

• Current experience with understanding claims adjudication, systems and reporting

• Knowledge in healthcare related applications and technology

• Ability to manage and prioritize multiple initiatives with minimal guidance

• Excellent communication and presentation skills to include the ability to communicate and present…