Director of Fraud Waste & Abuse Special Investigations Unit

POSITION SUMMARY:

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.

Position: Director of Fraud Waste & Abuse Special Investigations Unit

Department: BMCHP Compliance

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

• 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.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

REQUIRED EDUCATION AND EXPERIENCE:

• 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

PREFERRED EDUCATION AND EXPERIENCE:

• Master's degree in Health Law or Juris Doctor (JD)

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

• Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), Certified Financial Crimes Investigator (CFCI), or similar certification

CERTIFICATES, LICENSES, REGISTRATIONS PREFERRED:

• N/A

KNOWLEDGE, SKILLS & ABILITIES (KSAs):

• Knowledge of Medicare, Medicaid, and commercial health plan operations, including claims processing, provider reimbursement methodologies, and applicable federal and state regulatory requirements.

• Knowledge of FWA risk assessment methodologies and program development best practices within a managed care or health plan environment.

• Ability to plan, lead, and document complex healthcare fraud investigations, including interactions with federal and state regulators and law enforcement agencies.

• Ability to analyze and interpret complex datasets to identify fraud patterns, draw actionable insights, and support investigative and strategic decision-making.

• Skill in developing and implementing fraud detection frameworks, governance structures, and program performance metrics.

• Skill in written and oral communication sufficient to prepare formal reports, regulatory correspondence, and executive-level briefings.

• Ability to manage multiple concurrent investigations and program initiatives, adjusting priorities in response to evolving regulatory or organizational demands.

• Ability to exercise sound judgment and maintain confidentiality when handling sensitive investigative, legal, and compliance matters.

Compensation Range:

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensures as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, BMCHS offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), discretionary annual bonuses and merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family well-being.

NOTE: This range is based on Boston-area data, and is subject to modification based on geographic location.

Equal Opportunity Employer/Disabled/Veterans

According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not ask or require downloads of any applications, or "apps" job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment.