Administrator, Program Integrity Resume

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Administrator, Program Integrity Resume Jun Guerra Administrator, Program Integrity (916) 555-4832 jun.guerra@example.com linkedin.com/example/junguerra Sacramento, CA 95818 STRENGTHS Executive judgment Briefed leaders on credible allegations, financial exposure, and regulatory risk. Clear recommendations helped executives act with confidence. Risk prioritization Combined claims patterns, audit findings, provider history, and financial data. Teams gained a sharper route through competing case demands. Investigation leadership Set practical case standards across investigators, auditors, and analysts. Colleagues turned to this approach when facts were incomplete. Partner coordination Connected CMS, counsel, auditors, law enforcement, contractors, and providers. Difficult matters moved forward through steady communication. Public stewardship Protected health care funds while preserving due process and access. That balance shaped corrective actions providers could follow. SKILLS Medicaid Program Integrity Fraud, Waste, and Abuse Regulatory Compliance Investigations Compliance Audits Provider Oversight Risk Assessment Claims Analytics Performance Management Strategic Planning Budget Management Contract Oversight CMS Coordination Executive Communication Administrative Proceedings LANGUAGES English Native 40 Spanish Intermediate 20 MY CAREER 15.7 Years Deputy Director, Medicaid Program Integrity at Sierra Health Financing Agency (4.8 Years) Chief, Compliance and Investigations at Pacific Public Benefits Department (3.4 Years) Program Integrity Manager at Central Valley Medicaid Services (3.2 Years) Senior Compliance Analyst at Western Health Oversight Commission (2.7 Years) Program Compliance Specialist at Metro County Health Programs (1.6 Years) SUMMARY Medicaid program integrity executive with 15 years of progressively responsible experience, including more than nine years leading multidisciplinary teams across fraud, waste, and abuse investigations, financial and compliance audits , provider oversight, claims analytics, risk assessment, and regulatory operations. Directs complex statewide portfolios that protect public health care funds while balancing due process, provider relationships, access, and compliance obligations. Sets strategy, performance objectives, budgets, contracts, staffing plans, and investigative priorities for high visibility government health programs. Advises executives, legal counsel, auditors, regulators, and operational partners on credible allegations, financial exposure, corrective action, and policy risk. Builds productive relationships with CMS, Medicaid Fraud Control Units, law enforcement, contractors, providers, and oversight bodies. Prepared to bring disciplined judgment and public service commitment to senior program integrity leadership. EXPERIENCE Deputy Director, Medicaid Program Integrity Sierra Health Financing Agency January 2022 - Present Sacramento, CA Direct statewide Medicaid integrity operations covering investigations, audits, analytics, provider oversight, FWA prevention, budgets, contracts, and executive advisory work. Directed statewide Medicaid investigations , audits, analytics, and provider oversight for multidisciplinary integrity teams. Created risk reviews combining claims data, audit findings , referrals, provider patterns, and financial information . Coordinated CMS , fraud control, auditors, counsel, managed care partners, and providers on corrective actions. Managed budgets, contracts , staffing plans, and performance objectives against workload and compliance deadlines. Briefed executives and task forces on fraud allegations, payment risk, regulatory exposure, and corrective strategies. Represented agency interests during technical forums, interagency meetings, and administrative matters involving public funds. Chief, Compliance and Investigations Pacific Public Benefits Department July 2018 - December 2021 Oakland, CA Led managers responsible for health program investigations, compliance reviews, audit response, provider monitoring, case standards, and executive reporting. Led managers overseeing investigations , compliance reviews, audit response, and provider monitoring across health programs. Built case procedures linking allegations, evidence, financial impact, referrals, corrective actions, and counsel review. Integrated payment data, complaints, audit exceptions, and provider history into defensible risk assessments. Negotiated provider resolutions with counsel while preserving records for administrative proceedings and enforcement referrals. Briefed executives on investigative trends, material cases, constraints, and regulatory changes affecting policy priorities. Strengthened coordination with auditors, law enforcement , federal contacts, contractors, and health care organizations. Program Integrity Manager Central Valley Medicaid Services March 2015 - June 2018 Fresno, CA Managed investigators, auditors, and analysts conducting Medicaid provider reviews, payment integrity inquiries, compliance monitoring, referrals, training, and performance reporting. Managed investigators, auditors, and analysts conducting Medicaid reviews, payment inquiries, and compliance monitoring. Introduced triage using financial exposure, beneficiary impact, allegation credibility, and regulatory risk. Reviewed workpapers, investigative reports, claims analyses, and provider responses before escalation. Coordinated suspected fraud referrals with government attorneys and investigative partners using complete case records. Developed measures for case aging, audit completion, recoveries, referrals, and corrective actions. Trained staff on FWA indicators, documentation standards, referral practices, and emerging Medicaid risks. Senior Compliance Analyst Western Health Oversight Commission June 2012 - February 2015 San Jose, CA Conducted complex compliance reviews for publicly funded health care providers, analyzing billing, documentation, contracts, claims, financial records, and corrective actions. Conducted compliance reviews of providers, billing records, documentation, contracts, and program requirements. Analyzed claims and financial records for duplicate billing, unsupported services, and anomalous utilization. Prepared memoranda connecting evidence, regulations, financial findings, and recommended management actions. Organized exhibits and analytical methods for administrative cases and counsel questions. Facilitated provider conferences on findings and corrective actions with an objective regulatory posture. Proposed monitoring changes after identifying recurring control weaknesses across compliance work plans. Program Compliance Specialist Metro County Health Programs October 2010 - May 2012 Long Beach, CA Performed county health program monitoring, reviewing provider documentation, payments, contracts, policies, billing patterns, case files, and operational controls. Monitored provider documentation, payments, contracts, and policies for program exceptions. Researched questionable billing and service patterns for senior analyst review. Maintained evidence trails, correspondence, analytical notes, and disposition records for audit readiness. Produced Excel summaries of payment and utilization trends for focused provider monitoring. Coordinated information requests with provider offices and operations teams, escalating material concerns. Contributed training materials covering billing integrity, recordkeeping, referrals, and public fund stewardship. PROJECTS Statewide Risk Review Framework 2022 Public funds deserve disciplined attention. Built an integrated review model using claims analytics, audit findings, provider patterns, referrals, and financial information to focus investigative resources on emerging Medicaid risks. Provider Resolution and Referral Model 2021 Trust grows when decisions are clear and defensible. Developed documented pathways connecting allegations, evidence, counsel review, provider response, corrective action, and enforcement referral. LEADERSHIP & AWARDS Steering Committee Member, Government Health Program Integrity Roundtable, supported peer learning across public sector integrity programs. Mentor, Public Sector Compliance Leadership Forum, guided emerging managers through practical decisions in investigations and regulatory operations. Certified Fraud Examiner, recognized professional preparation in fraud examination, evidence review, and investigative practice. EDUCATION Master of Public Administration California State University, Sacramento GPA: 0 2014 Sacramento, CA Coursework: Public policy, public budgeting, program evaluation, organizational leadership Bachelor of Science in Health Administration California State University, Long Beach GPA: 0 2010 Long Beach, CA Coursework: Healthcare finance, health policy, compliance management, healthcare operations CERTIFICATIONS Certified Fraud Examiner 2016 Certified in Healthcare Compliance 2017 TECHNICAL SKILLS Program Integrity: Medicaid, Fraud Examination, Payment Integrity Investigations: Case Management, Evidence Review, Allegation Triage Auditing: Compliance Audits, Financial Audits, Audit Workpapers Analytics: Claims Analytics, Financial Analysis, Excel Provider Oversight: Provider Monitoring, Corrective Actions, Resolution Regulatory Compliance: Regulatory Research, Policy Review, Compliance Reviews Risk Management: Risk Assessment, Risk Prioritization, Control Review Government Relations: CMS Coordination, Federal Oversight, Law Enforcement Legal Proceedings: Administrative Proceedings, Counsel Review, Case Exhibits Management: Strategic Planning, Budget Management, Performance Management Contract Administration: Contract Oversight, Staffing Plans, Vendor Coordination Executive Communication: Executive Briefings, Technical Assistance, Stakeholder Engagement SKILLS Medicaid Program Integrity Fraud, Waste, and Abuse Regulatory Compliance Investigations Compliance Audits Provider Oversight Risk Assessment Claims Analytics Performance Management Strategic Planning Budget Management Contract Oversight CMS Coordination Executive Communication Administrative Proceedings PROFESSIONAL AFFILIATIONS Government Health Program Integrity Roundtable, Steering Committee Member. Public Sector Compliance Leadership Forum, Mentor. LANGUAGES English (Native) Spanish (Intermediate) ADDITIONAL INFORMATION Work Status : Authorized to work in United States. No sponsorship required. ADDITIONAL INFORMATION Work Status : Authorized to work in United States. No sponsorship required. REFERENCES AVAILABLE ON REQUEST

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