Director of Fraud Waste & Abuse Special Investigations Unit
About The Position
The Director of Fraud, Waste, and Abuse (FWA) / Special Investigations Unit (SIU) leads the enterprise-wide FWA program across Medicare, Medicaid, commercial, and delegated vendor lines of business. Reporting to the Vice President of Compliance and WellSense Compliance Officer, the Director operates with a high degree of autonomy and strategic authority, exercising direct supervisory responsibility over a team of investigators, a data analyst, and program coordinator. The position drives the design and execution of multi-year program strategy, advances fraud detection and predictive analytics capabilities, and ensures organizational compliance with applicable federal, state, and contractual regulatory requirements. Through governance oversight, complex case direction, and executive-level advisory functions, the Director delivers measurable impact on organizational revenue protection, program integrity, and risk reduction across the health plan.
Requirements
- Bachelor’s degree in criminal justice, business administration, healthcare management, or a related field; and at least 10 years of experience in healthcare fraud investigations, compliance, payment integrity, or related field, of which at least 5 years must be leadership experience managing FWA SIU programs and teams in a multistate health plan with diversified product portfolio; or equivalent combination of education and experience
Nice To Haves
- Master’s degree in Health Law or Juris Doctor (JD)
- Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), Certified Financial Crimes Investigator (CFCI), or similar certification
Responsibilities
- Develops and executes a comprehensive, multi-year FWA/SIU strategic roadmap, aligning program priorities, resource allocation, and performance targets with organizational goals and federal and state regulatory requirements.
- Establishes and maintains enterprise fraud risk management frameworks, governance structures, policies, procedures, and work plans; defines and monitors performance metrics to evaluate program effectiveness and ensure sustained operational excellence.
- Directs complex investigations involving providers, members, vendors, employees, and organized fraud schemes, ensuring adherence to established case prioritization protocols, documentation standards, and quality assurance requirements.
- Leads and develops a team of five to ten investigators and program support staff, providing coaching, performance management, and strategic direction while fostering a team culture of accountability, collaboration, and innovation.
- Leads the maturation of advanced fraud detection and predictive analytics capabilities, leveraging AI-enabled technologies and data-driven methods to proactively identify and mitigate fraud vulnerabilities across all product lines.
Benefits
- medical, dental, vision, pharmacy
- discretionary annual bonuses and merit increases
- Flexible Spending Accounts
- 403(b) savings matches
- paid time off
- career advancement opportunities
- resources to support employee and family well-being
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What This Job Offers
Job Type
Full-time
Career Level
Director
