Director of Fraud Waste & Abuse Special Investigations Unit
$122,000–$177,000 year
Remote · United States
Job Summary
Director of Fraud Waste & Abuse (FWA) SIU leads enterprise-wide FWA program across Medicare, Medicaid, commercial and delegated vendor lines. Reports to Vice President of Compliance and WellSense Compliance Officer. Supervises investigators, a data analyst, and a program coordinator. Builds multi-year FWA/SIU strategy, governance structures, policies, and metrics. Directs complex investigations involving providers, members, vendors, employees, and organized fraud schemes; fosters a culture of accountability and innovation. Advances fraud detection and predictive analytics capabilities using AI-enabled technologies and data-driven methods. Emphasizes regulatory compliance and risk reduction across product lines.
Required Qualifications
- Bachelor’s degree in criminal justice, business administration, healthcare management, or a related field
- at least 10 years of experience in healthcare fraud investigations, compliance, payment integrity, or related field
- at least 5 years of leadership experience managing FWA SIU programs and teams in a multistate health plan with diversified product portfolio
- Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), Certified Financial Crimes Investigator (CFCI), or similar certification
- Knowledge of Medicare, Medicaid, and commercial health plan operations
- Knowledge of FWA risk assessment methodologies and program development best practices
- Ability to plan, lead, and document complex healthcare fraud investigations
- Ability to analyze and interpret complex datasets to identify fraud patterns
- Ability to develop and implement fraud detection frameworks, governance structures, and program performance metrics
- Excellent written and oral communication skills
- Ability to manage multiple concurrent investigations
Apply with one swipe on Sorce. We auto-fill applications and apply on your behalf — no cover letters, no 40-minute forms.
Hiring someone like this?
Get your role in front of qualified candidates on Sorce.