Director, Fraud Detection & Prevention

MTM, Inc.•Saint Louis, MO

70d•Hybrid

About The Position

The Director, Fraud Detection & Prevention plays a critical leadership role in driving the organization's strategy to identify, mitigate, and address instances of fraud, inefficiency, and abuse. This position leads the Special Investigations Unit (SIU), oversees high-level investigations, and ensures adherence to all applicable federal and state regulations, including those governing Medicare and Medicaid programs. Location: Must reside in the St. Louis, MO area. This is a hybrid role of work from home and in office work at our Lake St. Louis, MO office location.

Requirements

Bachelor's degree required, preferably in a business-related field
7-10 years of experience in healthcare fraud investigations or regulatory compliance
Experience with case management systems, forensic tools, and data analytics platforms
Experience managing cross-functional teams and external audits
Excellent organizational skills
Ability to multi-task and set priorities in a fast-paced environment
Ability to handle confidential information in a professional manner
Ability to make solid judgment calls
Conduct all activities in an organized, timely and responsible manner
Ability to gain and maintain knowledge of all department responsibilities preferred
Proficiency with MS Office Suite
Demonstrate excellent time management skills
Ability to work within a team-oriented environment
Ability to identify, interpret and communicate business risks
Ability to lead, coach and motivate a specialized compliance team
Detail oriented, with excellent communication skills
Data analysis and interpretation skills
Ability to schedule, organize and prioritize multiple tasks
Excellent problem-solving skills with the ability to anticipate and resolve problems
Ability to maintain positive attitude and team focused during high stress situations
Ability to maintain high level of confidentiality
Strong understanding of Medicare, Medicaid, and commercial insurance programs
Familiarity with whistleblower protections and internal control
Deep understanding of regulatory frameworks and enforcement mechanisms

Nice To Haves

Master's degree in a related field a plus
Professional certifications such as CFE (Certified Fraud Examiner), CIA, or similar strongly preferred

Responsibilities

Develop and implement a comprehensive FWA prevention and detection program across the organization
Lead investigations into suspected fraud, waste, or abuse, ensuring timely resolution and appropriate corrective actions
Draft, revise, and enforce FWA-related policies and procedures
Design and deliver targeted training programs for high-risk departments and roles
Develop dashboards and KPIs to monitor FWA trends and program effectiveness
Leverage predictive analytics, AI tools, and forensic software to proactively detect anomalies and suspicious patterns
Establish and maintain reporting mechanisms for suspected FWA, including anonymous hotlines and digital platforms
Monitor industry trends, regulatory changes, and geopolitical risks that may impact FWA exposure
Conduct risk assessments and data analytics to identify patterns and vulnerabilities
Oversee training and awareness programs to educate employees on FWA policies and ethical conduct
Prepare detailed reports for executive leadership
Ensure compliance with federal, state, and industry-specific regulations (e.g., HIPAA, CMS, DOJ guidelines)
Monitor emerging threats and trends in fraud and abuse, adapting strategies accordingly
Other duties as assigned