Program Integrity Director Jobs in Fitchburg, WI

Role Snapshot  
 

The Contractor Medical Director (CMD) is responsible for researching and reviewing clinical evidence in support of developing Local Coverage Determinations (LCDs), conducting medical review (MR) activities, providing clinical program outreach activities, taking party or participant status in Administrative Law Judge (ALJ) appeals hearings, and performing appeals. The role collaborates with CMS and other Medicare Administrative Contractors (MAC) and interacts with medical societies and peer groups to share information, provide education and guidance. The CMD collaborates with multi-disciplinary teams to support accurate, timely, and consistent medical decision-making while promoting program integrity and high-quality care for Medicare beneficiaries. 

Salary Range  

275,000-300,000  (may be higher based on experience) 

The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience. 

 
Work Location 
Our first consideration will be to have this employee live in the state of Wisconsin to take advantage of Hybrid work and collaboration. Employees within 45 miles of WPS Headquarters (1717 W. Broadway in Madison, WI, 53713) will be expected to be able to be able to work Hybrid 2 days a week on a regular basis. 
**As a secondary consideration, we do offer remote work in the following approved states:  Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin 
*** If not regionally local to Madison, WI, occasional travel to our WPS Headquarters (1717 W. Broadway in Madison, WI, 53713) may be expected, as will some travel to CMS conferences.

How do I know this opportunity is right for me?  If you enjoy the following:  

• Research and review clinical evidence in support of developing Local Coverage Determinations (LCDs). 

• Work with RN(s) on local coverage determinations – reviewing new procedures that may involve new technology and provide medical judgment on coverage determinations.  

• Meet with CMS staff to provide input/updates on coverage and MR policy issues and interact with the CMDs at other contractors to share information on potential problem areas. 

• Work with the Medical Review (MR) Clinical Team to develop our MR strategy and provide clinical expertise to effectively focus MR on areas of potential fraud, waste, or abuse. 

• Analyze data to determine if there is an aberrancy with a particular service or provider and identify opportunities for improvement or interventions to address the issues. 

• Conduct claim reviews when appropriate and provide technical assistance on the correct application of MR policy during claim adjudication, including through written internal claim review guidelines. 

• Serve as subject matter expert for law enforcement with investigations regarding fraudulent provider activity. 

• Respond to inquiries from providers and representatives of the medical industry regarding advanced medical solutions that may provide better patient treatments and outcomes. 

• Other job-related responsibilities may be assigned as required. 

Minimum Qualifications  

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO). 

• Board Certification in an American Board of Medical Specialties recognized specialty. 

• Possession of a valid active and unrestricted medical license (in any state or U.S. territory) with no federal sanctions. 

• Five (5) or more years of experience as a practicing physician, with experience in Medicare insurance policies and regulations. 

• Three (3) or more years of experience in the health insurance industry, a utilization review firm, or another health care claims processing organization in a role that involved developing coverage or medical necessity policies and guidelines.  

• Strong knowledge of evidenced-based medicine and clinical guidelines. 

• Excellent written and verbal communication skills.  

Preferred Qualifications  

• Extensive knowledge of the Medicare Fee for Service program, particularly the coverage and payment rules, with Part A, Part B, DME, or Home Health and Hospice.  

Remote Work Requirements 

• Wired (ethernet cable) internet connection from your router to your computer.  

• High speed cable or fiber internet.  

• Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net). 

• Please review Remote Worker FAQs for additional information. 

 
Benefits 

• Remote and hybrid work options available 

• Performance bonus and/or merit increase opportunities 

• 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately) 

• Competitive paid time off 

• Health insurance, dental insurance, and telehealth services start DAY 1 

• Professional and Leadership Development Programs  

• Review additional benefits: (https://www.wpshealthsolutions.com/careers/) 

Who We Are 

WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.  

Culture Drives Our Success 

WPS’ culture is where the great work and innovations of our people are seen, fueled and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce—both current and future—to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities. 

We are proud of the recognition we have received from local and national organization regarding our culture and workplace:  WPS Newsroom - Awards and Recognition. 

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 Medicare (GHA) 

This position supports services under Centers for Medicare & Medicaid Services (CMS) contract(s). As such, the role is subject to all applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. CMS contractors and their personnel are subject to screening and background investigation including fingerprinting prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services