Dir Special Investigations Uni

Amerihealth Caritas•,

6d•Remote

About The Position

The Director, Special Investigations Unit (SIU) provides enterprise leadership for the prevention, detection, investigation, remediation, and reporting of healthcare fraud, waste, and abuse across Medicaid, Medicare, pharmacy, behavioral health, dental, transportation, and other products and services. The Director establishes SIU strategy, governance, and operating standards; leads managers and investigative professionals; and ensures investigations are timely, well documented, legally supportable, and compliant with federal and state requirements and contractual obligations. The role uses data analytics and AI-assisted fraud detection where permitted by regulatory and contractual requirements and collaborates across functions to address fraud, waste, and abuse. The Director partners with Legal, Finance, Clinical, Network, Claims, Data Analytics, market leadership, and external agencies to address emerging risks, strengthen program integrity, recover overpayments, and prevent future losses. The role oversees case intake, triage, analytics, investigations, referrals, recoveries, audit readiness, and performance reporting. It represents the organization and/or supports the Chief Compliance & Privacy Officer, Market Compliance Directors, and/or Market Leadership with regulators, law enforcement, and program-integrity partners. The position reports to the Chief Compliance & Privacy Officer and sits within the Compliance Program. This is a remote position within the United States, with work scheduled on Eastern Standard Time and an expectation of 25% travel within the Markets.

Requirements

Bachelor’s degree in criminal justice, healthcare administration, business, accounting, finance, law, compliance, data analytics, or a related field.
Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI), or ability to obtain one within 12 months of hire.
At least 10 years of experience in healthcare fraud, waste, and abuse, SIU, program integrity, compliance, investigations, or a related area, including at least 5 years leading managers or investigative teams in a managed care, health plan, government program, or similarly regulated environment.
Expert knowledge of healthcare fraud, waste, and abuse schemes; SIU and program-integrity requirements; Medicaid and Medicare regulations; managed care contracts; claims adjudication and reimbursement; overpayment recovery; investigative standards; evidence handling; interviewing; reporting and referral protocols; civil and criminal fraud concepts; and audit and record-retention expectations.
Demonstrated ability to set enterprise strategy, lead managers and geographically dispersed teams, establish performance measures, manage competing priorities, and drive consistent execution in a matrixed organization.
Ability to interpret claims and investigative data, identify aberrant billing patterns, evaluate sampling and data-mining results, and use case-management, fraud-detection, reporting, and Microsoft Office tools.
Executive-level written, verbal, presentation, negotiation, and stakeholder-management skills, including the ability to explain complex investigative and regulatory matters to varied audiences.
Sound decision-making, discretion, objectivity, and a high degree of integrity when handling sensitive, privileged, confidential, and personally identifiable information.
Ability to partner with HR, Legal, Operational, and Markets teams on joint investigation processes.
Ability to build effective relationships with regulators, law enforcement, Medicaid Fraud Control Units, government program-integrity organizations, legal counsel, providers, vendors, and industry partners.
Ability to manage case quality, timeliness, pre-payment cost avoidance, recoveries, referrals, audit readiness, vendor performance, budgets, and continuous-improvement initiatives using measurable outcomes.

Nice To Haves

Master’s degree in business, healthcare administration, public administration, law, compliance, or a related field.
Certified Insurance Fraud Investigator (CIFI), Certified in Healthcare Compliance (CHC), Certified Internal Auditor (CIA), or Certified Public Accountant (CPA).
Experience leading an enterprise or multi-market SIU function across Medicaid, Long Term Supports & Services, Medicare, and/or Marketplace.
Exposure to pharmacy, behavioral health, dental, transportation, or other delegated services.
Familiarity with artificial intelligence, machine learning, and project plans.

Responsibilities

Set SIU strategy and governance for enterprise fraud, waste, and abuse prevention, detection, investigation, remediation, pre-payment cost avoidance, recovery, and referral activities, aligning priorities with regulatory, contractual, and business requirements.
Lead and develop SIU leadership and investigative teams by setting SMART goals, allocating resources, managing performance, building capability, and maintaining consistent investigative quality across markets and products.
Oversee the end-to-end case lifecycle, including intake, triage, assignment, investigative strategy, evidence development, quality review, disposition, referral, pre-payment cost avoidance, recovery, closure, and case-management documentation.
Direct analytics and surveillance using claims data, fraud-detection tools, sampling methodologies, trend analysis, and internal and vendor intelligence to identify aberrant patterns and prioritize high-risk matters; provide regular and requested updates to Compliance, Market, and Enterprise Leadership teams.
Ensure compliance with applicable federal and state program-integrity, reporting, referral, prepayment cost-avoidance and recovery, record-retention, and audit requirements; maintain policies, procedures, controls, and audit-ready evidence.
Build cross-functional remediation and prevention plans with Compliance, Legal, Finance, Clinical, Claims, Network, Pharmacy, Operations, and market leadership to address root causes, reduce exposure, and strengthen controls.
Lead pre-payment cost avoidance, overpayment recovery, and settlement support; ensure findings are well supported and actions are timely, and coordinate matters requiring legal review, litigation support, or negotiated resolution.
Represent the organization with state and federal agencies, Medicaid Fraud Control Units, law enforcement, regulators, auditors, and other program-integrity partners as requested.
Provide executive reporting and lead committees by communicating FWA trends, material cases, financial impact, operational performance, emerging risks, and recommended actions to senior leaders and governance bodies.
Drive continuous improvement by monitoring performance indicators, investigation quality, cycle time, cost avoidance, recoveries, referral outcomes, and control effectiveness, and implement training, technology, workflow, and policy enhancements.