Director of Fraud Investigations

Job Summary

To enhance fraud detection capabilities, the remote Director of Fraud Investigations will manage a portfolio of fraud investigations from intake to resolution, collaborating with legal teams and stakeholders to ensure thorough documentation and compliance with regulatory standards.

Key responsibilities

• Investigate suspected fraud end-to-end, developing investigative plans and analyzing evidence
• Handle ad hoc internal referrals, providing factual assessments of potential fraud cases
• Coordinate legal support for investigations, ensuring compliance with legal guidance and standards

Required qualifications

• 7+ years of experience in healthcare fraud investigations or SIU operations, particularly within Medicare Advantage
• Management experience overseeing segments of SIU work or specific fraud categories
• Strong understanding of healthcare fraud schemes and the ability to analyze claims data and medical records
• Familiarity with Medicare Advantage regulatory requirements and federal fraud frameworks
• Ability to communicate complex investigative findings clearly in written and verbal formats