[Hiring] Director, Special Investigations Unit @Amerihealth Caritas

Role Description

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 role requires a leader who can adapt to the rapidly transforming healthcare compliance landscape by leveraging data analytics, AI assisted fraud detection, as permitted by regulatory and contractual requirements, and cross-functional collaboration to prevent, detect and address fraud, waste, and abuse.

• Establishes SIU strategy, governance, and operating standards.
• Leads managers and investigative professionals.
• Ensures investigations are timely, well documented, legally supportable, and compliant with federal and state requirements and contractual obligations.
• 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.
• Oversees case intake, triage, analytics, investigations, referrals, recoveries, audit readiness, and performance reporting.
• 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.

Qualifications

• Bachelor’s Degree in criminal justice, healthcare administration, business, accounting, finance, law, compliance, data analytics, or a related field, required.
• Master’s Degree in business, healthcare administration, public administration, law, compliance, or a related field preferred.
• Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) required, or ability to obtain within 12 months of hire.
• Certified Insurance Fraud Investigator (CIFI), Certified in Healthcare Compliance (CHC), Certified Internal Auditor (CIA), or Certified Public Accountant (CPA) preferred.
• 10+ years of Healthcare fraud, waste, and abuse, SIU, program integrity, compliance, investigations, or related experience, including at least 5 years leading managers or investigative teams in a managed care, health plan, government program, or similarly regulated environment, required.
• 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; and experience interacting with regulators, law enforcement, and program integrity agencies.
• Familiarity with artificial intelligence, machine learning, and project plans, preferred.

Requirements

• Sets SIU strategy and governance for enterprise fraud, waste, and abuse prevention, detection, investigation, remediation, pre-payment cost avoidance, recovery, and referral activities.
• Leads and develops SIU leadership and investigative teams by establishing SMART goals, allocating resources, managing performance, building capability, and maintaining consistent investigative quality.
• Oversees 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.
• Directs analytics and surveillance activities using claims data, fraud-detection tools, sampling methodologies, trend analysis, and internal and vendor intelligence.
• Ensures regulatory and contractual compliance with applicable federal and state program-integrity, reporting, referral, prepayment cost avoidance and recovery, record-retention, and audit requirements.
• Builds cross-functional remediation and prevention plans with Compliance, Legal, Finance, Clinical, Claims, Network, Pharmacy, Operations, and market leadership.
• Leads pre-payment cost avoidance and overpayment recovery and settlement support.
• Represents the organization with external stakeholders, including state and federal agencies, Medicaid Fraud Control Units, law enforcement, regulators, auditors, and other program-integrity partners.
• Provides executive reporting and committee leadership by timely communicating FWA trends, material cases, financial impact, operational performance, emerging risks, and recommended actions to senior leaders and governance bodies.
• Drives continuous improvement by monitoring performance indicators, investigation quality, cycle time, cost avoidance, recoveries, referral outcomes, and control effectiveness.

Benefits

• Flexible work solutions include remote options and hybrid work schedules.
• Competitive pay.
• Paid time off, holidays, and volunteer events.
• Health insurance coverage for you and your dependents starting Day 1.
• 401(k) retirement savings plan.
• Tuition reimbursement.
• And more.