Program Integrity Manager

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Summary The Program Integrity Manager serves as a key leader supporting Medicaid Program Integrity, Payment Integrity, and Special Investigations Unit (SIU) activities for the New Jersey Medicaid Health Plan . This role is responsible for ensuring compliance with state and federal requirements, supporting fraud, waste, and abuse (FWA) prevention efforts, overseeing regulatory and contractual obligations, coordinating reporting and audit activities, and partnering with internal and external stakeholders to promote operational effectiveness and program integrity. The position works closely with health plan leadership, Compliance, Legal, Clinical, Provider Relations, Analytics, Operations, SIU, and external vendors to drive strategic initiatives, lead cross-functional projects, facilitate meetings and workgroups, and identify opportunities for innovation and process improvement. The Program Integrity Manager must be able to influence stakeholders, obtain buy-in, present to diverse audiences, and lead initiatives from concept through implementation.

5+ years of experience in Program Integrity, Payment Integrity, SIU, Healthcare Compliance, FWA, Claims Operations, Healthcare Operations, or a related field, including experience in a leadership, supervisory, management, or project lead capacity. Knowledge of healthcare regulatory and compliance requirements. Strong analytical, organizational, communication, and problem-solving skills. Demonstrated experience leading projects, initiatives, meetings, and cross-functional workgroups. Experience partnering with multiple business areas and external stakeholders to achieve business objectives. Strong presentation and facilitation skills with the ability to communicate effectively to leadership and stakeholder groups. Proven ability to drive process improvements, lead ideation efforts, gain stakeholder buy-in, and influence decision-making. Ability to manage multiple priorities and work effectively in a collaborative environment.

Experience supporting Medicaid managed care programs. Experience with regulatory reporting, audits, compliance initiatives, or operational oversight activities. Experience working with SIU investigations, fraud prevention programs, vendor management, or payment integrity operations. Knowledge of healthcare claims, provider reimbursement, payment accuracy, and program integrity practices. Project management experience leading strategic or operational initiatives across multiple business partners.

Bachelor's degree or equivalent combination of education and experience. **We support a hybrid work environment. If selected and you live near a suitable work location, you may be expected to comply with the hybrid work policy.  Under the policy, all hires for in-scope populations should be placed into a hybrid or office-based location, working onsite three days a week. Aetna Service Operations office/hub locations will be discussed with the selected candidate. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $54,300.00 - $145,860.00 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive