Program Integrity Manager

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.

At Sun Life, we're driven by our Purpose: helping our Clients achieve lifetime financial security and live healthier lives. Our values shape how we work: caring, authentic, bold, inspiring, and impactful.

When you join Sun Life, you'll work with passionate colleagues and empowering leaders who support your growth and celebrate your contributions, so you can make a meaningful difference in our Clients' lives.

Visit our website to discover how Sun Life is making life brighter for our customers, partners and communities.  

DentaQuest 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 in the contiguous states plus AK. ​

**Candidate Must Reside in Iowa.

The opportunity:
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 DentaQuest 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.

How you will contribute:

• Provide leadership and strategic oversight of DentaQuest 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, defensible, and properly documented.

• Ensure all investigative, audit, and recovery actions comply with CMS rules and regulations and internal policies and procedures.

• Serve as primary client and provider liaison for all fraud, waste, and abuse investigations and program integrity client meetings.

• Track investigations, manage workflows independently, which include client reporting requirements.

• Support policy and procedure improvements and foster interdepartmental collaborations to strengthen program integrity outcomes.

What you will bring with you:

• Must reside in Iowa

• Bachelor’s degree from an accredited four-year college or university is required

• 9+ years of experience in compliance, legal or regulatory functions or combined education and/or full-time experience in any field and profession in any field (e.g., public or business administration, social work, public health, law, education, engineering)

• Demonstrate knowledge and experience in managing health care delivery, program integrity, utilization management, or public health program functions within a large health plan or programs

• Comprehensive knowledge of laws, policies, and regulations that apply to the administration of Medicaid Managed Care program health care delivery and program integrity

• Demonstrate ability to use knowledge and associated metrics to assess and improve program effectiveness, management processes, and systems to achieve program integrity priorities and results.

• Demonstrate experience, in a senior leadership position working with government agencies and programs, law enforcement organizations, and/or public and private organizations on complex and controversial issues related to program integrity

• Ability to attend additional training as requested/deemed necessary

• Ability to attend in-person regulatory meetings with clients

• Ability to evaluate laws and regulations and identify and prioritize relevant content for updating policies and procedures

• Ability to interpret laws and regulations and communicate that information to management and line personnel

• Ability to research and investigate regulatory issues as they relate to the company’s operating subsidiaries and businesses

• Ability to discern risks and recommend controls to mitigate regulatory compliance

• Ability to assume a reasonable level of authority, to handle multiple projects and duties at the same time and to work collaboratively in a nonhierarchical department structure

• Ability to interface with various levels of management, as well as with internal and external clients and subject matter experts

• Strong writing skills, with extensive policy and procedure writing experience required

• Strong verbal communication skills

• Strong collaborative skills, as well as analytical, problem-solving and decision-making skills

• Meticulous organizational skills and attention to detail

• Strong PowerPoint and advanced Excel capabilities preferred

Salary:

Salary Range: $77,200 - $115,800

At our company, we are committed to pay transparency and equity. The salary range for this role is competitive nationwide, and we strive to ensure that compensation is fair and equitable. Your actual base salary will be determined based on your unique skills, qualifications, experience, education, and geographic location. In addition to your base salary, this position is eligible for a discretionary annual incentive award based on your individual performance as well as the overall performance of the business. We are dedicated to creating a work environment where everyone is rewarded for their contributions.           
            
            
            
            
            
            
            
            
 

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We are committed to fostering an inclusive environment where all employees feel they belong, are supported and empowered to thrive.  We are dedicated to building teams with varied experiences, backgrounds, perspectives and ideas that benefit our colleagues, clients, and the communities where we operate.  We encourage applications from qualified individuals from all backgrounds.

Life is brighter when you work at Sun Life

At Sun Life, we prioritize your well-being with comprehensive benefits, including generous vacation and sick time, market-leading paid family, parental and adoption leave, medical coverage, company paid life and AD&D insurance, disability programs and a partially paid sabbatical program.  Plan for your future with our 401(k) employer match, stock purchase options and an employer-funded retirement account.  Enjoy a flexible, inclusive and collaborative work environment that supports career growth.  We’re proud to be recognized in our communities as a top employer.  Proudly Great Place to Work® Certified in Canada and the U.S., we’ve also been recognized as a "Top 10" employer by the Boston Globe's "Top Places to Work" for two years in a row.  Visit our website to learn more about our benefits and recognition within our communities.

We will make reasonable accommodations to the known physical or mental limitations of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please email [email protected] to request an accommodation.

For applicants residing in California, please read our employee California Privacy Policy and Notice.

We do not require or administer lie detector tests as a condition of employment or continued employment.

Sun Life will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including applicable fair chance ordinances.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.