Program Integrity Director Jobs in Brandywine, MD

Summary
As a Program Manager, you will be part of Healthcare and Insurance, Office of Personnel Management. If selected, you will lead administrative program integrity operations that safeguard Federal health benefits programs by directing carrier compliance reviews, audit resolution, fraud prevention and detection activities, payment integrity oversight, corrective-action monitoring, contract-remedy support, and a multidisciplinary workforce while collaborating with government and industry partners.
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Duties
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• Direct administrative program integrity reviews involving potential fraud, waste, abuse, improper payments, control weaknesses, and other program integrity risks affecting Federal health benefits programs.
• Lead oversight of administrative reviews by evaluating program documentation, audit findings, referral information, claims and payment data, and other relevant materials to recommend corrective actions, recoveries, disallowances, sanctions-implementation steps, or other administrative remedy options.
• Oversee health insurance carriers' compliance with contractual and regulatory requirements by directing carrier compliance reviews, validating corrective actions, and resolving program integrity findings through appropriate administrative processes.
• Analyze program integrity trends, claims data, audit results, carrier submissions, and risk indicators to identify vulnerabilities, improper payment risks, control weaknesses, and opportunities to strengthen fraud prevention and detection efforts.
• Coordinate administrative review, referral, corrective-action, compliance, and contract-remedy activities with Offices of Inspector General, legal counsel, contracting officials, program offices, carriers, health care organizations, and other oversight partners.
• Develop policies, procedures, documentation standards, referral protocols, corrective-action processes, and performance measures that improve health insurance program integrity, accountability, and administrative oversight.
• Supervise a multidisciplinary workforce responsible for administrative program integrity reviews, carrier compliance oversight, audit resolution, payment integrity, corrective-action monitoring, referral coordination, and contract-remedy support.

Requirements
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Conditions of employment

• Must be a U.S. Citizen or National
• Males born after 12-31-59 must be registered or exempt from Selective Service (see https://www.sss.gov/Home/Registration)
• Suitable for Federal employment, determined by a background investigation
• May be required to successfully complete a probationary period
• Candidates will not be hired based on their race, sex, color, religion, or national origin
• Complete the initial online assessment and USAHire Assessment, if required.
• You will be required to report to an OPM assigned office.
• This position is not eligible for inclusion in a bargaining unit

Qualifications
For the GS 15: You must have You must have one full year (52 weeks) of specialized experience comparable in scope and responsibility to the GS-14 grade level or pay band in the Federal service (obtained in either the public or private sectors) performing ALL of the following:

• Providing administrative program integrity analysis and recommendations to address potential fraud, waste, abuse, improper payment risk, program vulnerabilities, or noncompliance involving public or private health insurance programs;
• Coordinating administrative review, referral, corrective-action, compliance, or contract-remedy activities with oversight organizations, legal counsel, contracting officials, health care organizations, carriers, program offices, or other stakeholders;
• Analyzing supporting documentation, audit findings, medical claims, billing data, financial records, carrier submissions, or other program information to identify potential Fraud, Waste, Abuse patterns, improper payment risks, control weaknesses, root causes, and options for administrative corrective action or contract remedies;
• Preparing referral packages, issue summaries, corrective-action recommendations, recovery or disallowance analyses, sanctions-implementation reviews, contract-remedy options, or other administrative review products supported by program integrity findings and appropriate documentation; AND
• Developing policies, procedures, documentation standards, referral protocols, and performance measures that support the prevention, detection, administrative review, referral coordination, corrective action, and resolution of fraud, waste, abuse, improper payment risk, and material control weaknesses in health insurance programs.

You must meet all qualification and eligibility requirements by the closing date of this announcement.
Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religious; spiritual; community, student, social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.
Education
There are no educational requirements for this position.
Additional information
Current OPM employees may be entitled to relocation expenses.
Incentive payments may be considered.
This job opportunity announcement may be used to fill additional similar vacancies across OPM.
If you are unable to apply online and would like to request information about the Alternate Application process, please use the contact information at the bottom of this announcement.
Career Transition Assistance Programs: These programs apply to employees who have been involuntarily separated from a Federal service position within the competitive service or Federal service employees whose positions have been deemed surplus or no longer needed. To receive selection priority for this position, you must: 1) meet CTAP or ICTAP eligibility criteria; 2) be rated well-qualified for the position (obtain score of 85 or higher on the assessments) and 3) submit the appropriate documentation to support your CTAP or ICTAP eligibility. For more information visit: http://www.opm.gov/rif/employee_guides/career_transition.asp.
Reasonable Accommodation Requests: If you believe you have a disability (i.e., physical or mental), covered by the Rehabilitation Act of 1973 as amended and Americans with Disabilities Act 1990 as amended, that would interfere with completing the USA Hire Competency Based Assessments, you will be granted the opportunity to request a reasonable accommodation in your online application. Requests for Reasonable Accommodations for the USA Hire Competency Based Assessments and appropriate supporting documentation for Reasonable Accommodation must be received prior to starting the USA Hire Competency Based Assessments. Decisions on requests for Reasonable Accommodations are made on a case-by-case basis. If you meet the minimum qualifications of the position, after notification of the adjudication of your request, you will receive an email invitation to complete the USA Hire Competency Based Assessments, based on your adjudication decision. You must complete all assessments within 48 hours of receiving the URL to access the USA Hire Competency Based Assessments, if you received the link after the close of the announcement. To determine if you need a Reasonable Accommodation, please review the Procedures for Requesting a Reasonable Accommodation for Online Assessments here: https://help.usastaffing.gov/Apply/index.php?title=Reasonable_Accommodations_for_USA_Hire
As a condition of employment for accepting this position, you may be required to serve a 1-year probationary period during which we will evaluate your fitness and whether your continued employment advances the public interest. In determining if your employment advances the public interest, we may consider:
- your performance and conduct;
- the needs and interests of the agency;
- whether your continued employment would advance organizational goals of the agency or the Government; and
- whether your continued employment would advance the efficiency of the Federal service.
Upon completion of your probationary period your employment will be terminated unless you receive certification, in writing, that your continued employment advances the public interest.
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Candidates should be committed to improving the efficiency of the Federal government, passionate about the ideals of our American republic, and committed to upholding the rule of law and the United States Constitution.
Benefits
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A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
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Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.