Program Integrity Manager, DentaQuest (Iowa)

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. 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. Job Description: Location: Must reside in Iowa, preferably close to Des Moines The opportunity: The Program Integrity Manager leads and oversees a Medicaid Managed Care program integrity operation, providing strategic direction, leadership, and oversight of special investigations and contractor activities to prevent and address fraud, waste, and abuse while upholding compliance regulations. 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 evaluate 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 direction and strategic oversight of DentaQuest’s Program Integrity and Special Investigations Unit (SIU) activities. Participate in and oversee Clinical Quality Management, FPR operations, and contractor activities to prevent, detect, and resolve fraud, waste, and abuse. Develop, implement, and continuously improve program integrity strategies aligned with Iowa Medicaid and Medicare requirements. Perform advanced data evaluation 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. Manage multiple clients and provider networks, ensuring contractual obligations, metrics, and reporting requirements are met. Partner with Dental Directors to ensure investigative judgements are clinically sound, defensible, and properly documented. Ensure all investigative, audit, and recovery actions comply with Medicare regulations, Medicaid guidelines, and internal policies. Lead provider accountability efforts, including recovery documentation, overpayment negotiations, and provider communications. Serve as primary client and provider liaison for all fraud, waste, and abuse investigations and client-facing meetings. Track investigative cases, manage workflows, and maintain accurate records in fraud tracking systems. Aid policy and process improvements and foster interdepartmental collaboration to strengthen program integrity outcome. What you will bring with you : Graduation from an accredited four-year college or university with a degree in any field 5 + years demonstrated experience in program administration, program development, program operations, or managed care direction and/or related investigative business experience. Experience in Dental Utilization Management or Review, preferred Located within the Des Moines, IA metro area. Knowledge of general computer software (Excel, Word, Outlook, Adobe). Clinical experience and knowledge of dental procedures and terminology is required. Effective oral communication and business writing skills are required. Attention to detail, accuracy and organizational skills are essential. Effective interpersonal skills are essential. Ability to prioritize and adapt to changing priorities is essential. Not ready to apply yet but want to stay in touch? Join our talent community to stay connected until the time is right for you! 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 accommodation s to the known physical or mental limitation s 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 vetera n. Job Category: Compliance Posting End Date: 13/05/2026