Medicare Medicaid Program Integrity Manager Jobs in Ridgeway, SC

Job Responsibilities The Agency's mission is to be boldly innovative in improving the health and quality of life for South Carolinians. This position is located the Operations and Managed Care Oversight, Richland County. This is an in-office role and not a telecommute or remote position.

Are you the One. We are looking for a Program Integrity Operations Supervisor, who will assists with providing mid-level operational leadership and coordination across all PI operational functions within the Operations and Managed Care Oversight (OMCO) unit. This position executes, organizes, and monitors key responsibilities, including financial reconciliation, managed care oversight activities, enforcement workflows, audit documentation, data validation, trend integration, and hearings support, ensuring these functions comply with federal and state Medicaid PI requirements.

The PI Operations Supervisor translates strategic direction from the OMCO Manager into actionable work plans, maintains workflow continuity, ensures accuracy of PI documentation, and coordinates cross unit activities that support audit readiness, managed care obligations, and enforcement actions. The role serves as the central operational hub for OMCO, ensuring efficient daily execution of PI activities while maintaining clear communication with the OMCO Manager regarding priorities, risks, barriers, and performance needs. Coordinates daily operational activities across OMCO PI functions, including managed care oversight, financial integrity tasks, provider sanction actions, and case management workflows.

Assigns tasks to PI coordinators, monitors progress, maintains operational calendars, and ensures timely completion of deliverables. Escalates emerging risks or barriers to the OMCO Manager with proposed solutions. Completes monthly PI financial reconciliation processes, validating recovery data across fee for service, managed care, Recovery Audit Contractor recoveries, global settlements, cost avoidance, and federal share requirements.

Ensures all recoveries are accurately entered into the PI case management system and reconciled against Surveillance and Utilization Review and Accounting Operations reports. Produces monthly activity reports and supports fiscal documentation for audits. Administers the provider payment suspension process in accordance with the PI Payment Suspension policy.

Maintains and updates the Payment Suspension SharePoint List and ensures accurate and timely execution of all system updates related to initiating or lifting provider payment suspensions. This function ensures adherence to federal regulations regarding provider suspension actions and minimizes improper payments to high-risk providers. Reviews federally sourced exclusion data through the Office of Inspector General (OIG) Extract Report, including information from the List of Excluded Individuals and Entities (LEIE) and the System for Award Management (SAM).

Compares federal exclusion data with the Data Exchange (DEX) Adverse Report to identify potential provider matches. Refers confirmed matches to the Provider Sanctions Coordinator for further review and potential sanctions action. This process ensures compliance with federal exclusion screening requirements and prevents prohibited providers from receiving Medicaid reimbursement.

Conducts compliance reviews of payments issued to providers, individuals, or entities that have been excluded or terminated from Medicaid participation. Identifies improper payments and ensures appropriate corrective actions are initiated to prevent sanctioned providers from receiving reimbursement. Coordinates with internal teams and external partners to support the recoupment of payments issued in error and maintains alignment with PI requirements.

This function directly mitigates improper payment risk and supports federally required post-sanction monitoring. Assembles, validates, and organizes documentation for federal, state, contractual, and internal audits involving PI and MCO Special Investigative Units (SIUs). Maintains audit repositories, tracking logs, versioning, and submission coordination.

Drafts corrective action plan (CAP) materials and ensures documentation consistency across sanctions, managed care, and financial teams. Maintains, tracks, and updates global and civil case files to support PI operations. Coordinates the collection and distribution of case-related documentation, including data requests, receipts, and accounts receivable materials.

Works collaboratively with the Provider Overpayment Coordinator to ensure accurate and timely processing of financial documentation associated with these cases. This work supports federal settlement management, audit preparation, and accurate financial tracking. Oversight of Prehearing Conference and provider Fair Hearing material preparation, including assembling required documentation, reviewing and finalizing scripts, and coordinating timely scheduling with all applicable personnel.

Ensure all required materials are complete and ready for use. Supports updates to PI internal policies. Reviews drafts, tracks revisions, ensures consistency, and maintains documentation repositories.

Responsible for performing other professional duties as assigned by the OMCO Manager. Serves as a subject matter resource related to program development and/or other program area development when related to PI operations. Supports agency adaptability and responsiveness to emerging federal and state PI requirements.

Enrollment and attendance in any training to provide knowledge regarding program integrity, MCO management, creative writing, or fraud, waste, and abuse. Ongoing training is essential to maintain current knowledge of evolving CMS guidance, federal regulations, audit expectations, and best practices in PI operations. The South Carolina Department of Health and Human Services offers an exceptional benefits package for FTE and TGE positions that includes: Health, Dental, Vision, Long Term Disability, and Life Insurance for Employee, Spouse, and Children.

15 days annual (vacation) leave per year. 15 days sick leave per year. 13 paid holidays.

State Retirement Plan and Deferred Compensation Programs. Minimum and Additional Requirements A bachelor's degree and two (2) years of professional experience in administrative or financial services, public administration or business management. An equivalent combination of education and experience may be considered with prior State Human Resources approval.

All degrees must be from a college or higher education institution recognized by the U.S. Department of Education & Council for Higher Education Accreditation (CHEA). Additional Requirements: Valid driver's license

Occasional overnight travel. Overtime and/or weekend work with Deputy approval. Sitting or standing for long periods of time Lifting requirements: 20 lbs.

In-office role. Preferred Qualifications Preferred qualifications include experience in Medicaid Program Integrity (PI) operations such as managed care oversight, financial reconciliation, and sanctions; knowledge of federal and state Medicaid requirements; and strong analytical and organizational skills. Candidates should be proficient with case management and documentation tools like SharePoint and able to prepare reports, manage workflows, and support audit and hearing activities.

Training or coursework related to PI, fraud, waste, and abuse, Medicaid operations, or managed care is also preferred. Additional Comments Please complete the State application to include all current and previous work history and education. A resume will not be accepted nor reviewed to determine if an applicant has met the qualifications for the position.

Supplemental questions are considered part of your official application for qualification purposes. All applicants must apply online. All correspondence from the Office of Human Resources will be through electronic mail.

The South Carolina Department of Health and Human Services is committed to providing equal employment opportunities to all applicants and does not discriminate on the basis of race, color, religion, sex (including pregnancy, childbirth or related medical conditions, including, but not limited, to lactation), national origin, age (40 or older), disability or genetic information.