Director, FWA, Pharmacy Network- Remote

Gainwell Technologies LLC•Any city, OH

10d•Remote

About The Position

We are seeking a seasoned, strategic, and mission-driven Director to lead our Medicaid Fraud, Waste & Abuse (FWA) and Pharmacy Network Management functions. In this role, you will oversee program integrity operations, shape pharmacy network strategy, and lead high-performing teams dedicated to protecting Medicaid dollars while ensuring strong pharmacy access and provider accountability. The ideal candidate brings deep Medicaid expertise, exceptional people leadership skills, and a passion for building compliant, data-driven, and operationally excellent programs. This leader directs multidisciplinary operations teams, partners closely with state Medicaid agencies, ensures adherence to federal and state regulations, and drives initiatives that strengthen program integrity and enhance member access, provider performance, and overall network value. The Director is responsible for setting strategy, managing people and processes, and delivering measurable results across both domains.

Requirements

Advanced degree or significant related experience
10+ years of pharmacy-related experience
Extensive experience in Medicaid program integrity, FWA operations, pharmacy network management, or related healthcare regulatory fields
Experience interacting with clients in the healthcare industry
Track record of cross-functional leadership of teams and projects spanning people, process, and technology
Excellent communication skills, with the ability to communicate externally and with senior executives
Innovative forward thinker with excellent leadership skills
Proven success leading teams and developing leaders
Strong understanding of Medicaid regulations, pharmacy operations, and provider network dynamics
Ability to build relationships with regulators, providers, and internal stakeholders
Strategic mindset with the ability to execute in a fast-paced, highly regulated environment

Responsibilities

Lead the vision, strategy, and execution of Medicaid FWA and pharmacy network management programs
Drive initiatives that strengthen program integrity, optimize network performance, and meet state Medicaid expectations
Monitor industry trends, regulatory changes, and emerging fraud schemes to proactively evolve program strategy
Manage and develop managers, analysts, investigators, and network operations staff
Build a collaborative, high-performance culture with clear goals, coaching, and professional growth opportunities
Ensure teams operate with integrity, accountability, and operational excellence
Oversee FWA detection, investigation, prevention, and reporting activities
Guide the use of analytics, audits, and surveillance tools to identify high-risk providers and suspicious billing patterns
Ensure timely case management, documentation, referrals, and corrective action plans
Partner with state agencies, law enforcement, and internal compliance teams on FWA matters
Direct the strategy, performance, and compliance of the Medicaid pharmacy network
Oversee contracting, credentialing, reimbursement methodologies, and network adequacy
Monitor pharmacy performance metrics and lead initiatives to improve access, quality, and cost-effectiveness
Address high-risk pharmacy behavior and support provider education and engagement
Serve as a primary liaison with state Medicaid agencies and regulatory bodies
Ensure accurate and timely submission of required reports, audits, and corrective action plans
Translate regulatory requirements into operational processes and team workflows
Establish KPIs, dashboards, and reporting to track FWA outcomes and network performance
Lead process improvements to enhance efficiency, accuracy, and compliance
Oversee vendor relationships supporting FWA analytics, SIU functions, and credentialing
Manage budgets, resource planning, and ROI analysis for program initiatives