Director, Compliance on Special Investigations Unit and Fraud, Waste and Abuse

Director, Compliance On Special Investigations Unit And Fraud, Waste And Abuse

The Director, Compliance on Special Investigations and Fraud, Waste and Abuse (FWA) is responsible for directing L.A. Care Health Plan's enterprise special investigations unit (SIU) and FWA program. The Director oversees internal and external investigations into potential misconduct, regulatory violations, and fraudulent activity while ensuring compliance with federal and state regulatory requirements.

The Director provides strategic direction, operational leadership, and subject matter expertise to safeguard L.A. Care's integrity, protect member trust, and mitigate financial and reputational risks. This position leads investigative governance across the enterprise, coordinating with internal stakeholders and external regulators to ensure timely, thorough, and effective resolution of investigative matters.

This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.

Duties

Leadership and Program Oversight :

Lead L.A. Care's Special Investigations Unit (SIU) in overseeing the internal and external investigations into fraud, waste, abuse, and compliance violations.

Drive the design, implementation, and continuous improvement of the Fraud, Waste, and Abuse (FWA) program, ensuring compliance with Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS), and state / federal requirements.

Ensure effective case intake, triage, investigation, tracking, and resolution processes, including referral to law enforcement, regulators, or external entities as needed.

Develop and support enterprise policies, procedures, and training programs supporting FWA prevention, detection, and response.

Investigations and Regulatory Engagement :

Direct and oversee investigations into allegations of non-compliance, ethical violations, or fraudulent behavior involving employees, delegated entities, providers, or vendors.

Partner with Legal, Compliance, and Human Resources on sensitive internal investigations to ensure confidentiality, integrity, and fairness.

Ensure timely and accurate reporting of SIU / FWA activity to external agencies to meet regulatory requirements.

Lead enterprise readiness for external audits, regulatory inquiries, and enforcement actions involving SIU and FWA matters.

Duties Continued

Risk Management and Oversight :

Conducts strategic planning to use resources to meet current and future departmental and Enterprise-wide goals.

Monitor investigative trends, emerging risks, and regulatory developments to proactively adapt investigative strategy and resource allocation.

Develop dashboards, analytics, and reporting tools to provide executives and the Board with visibility into investigative outcomes, financial recoveries, and risk trends.

Ensure alignment of investigative and FWA activities with organizational risk appetite, compliance strategy, and enterprise risk management frameworks.

Collaboration and Culture :

Serve as a trusted advisor and subject matter expert to senior leadership, the Compliance Committee, and the Audit Committee on investigative matters.

Collaborate with cross-functional leaders to embed FWA prevention and detection mechanisms across operations.

Champion a culture of integrity, accountability, and transparency by promoting awareness of FWA risks and prevention strategies.

Develops goals, objectives, and action plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews, and disciplinary matters for direct reporting employees. Manages budgets and resources effectively. Perform other duties as assigned.

Education Required

Bachelor's Degree in Criminal Justice or Related Field

In lieu of degree, equivalent education and / or experience may be considered.

Education Preferred

Master's Degree in Public Policy or Related Field

Experience

Required :

At least 7 years of experience in healthcare compliance, fraud investigations, law enforcement, or related field.

At least 5 years of experience in leading teams, projects, initiatives, or cross-functional groups.

Demonstrated experience managing complex investigations in a managed care or healthcare environment.

Experience in coordinating with external regulators and law enforcement agencies.

Preferred :

Prior leadership of a Special Investigations Unit (SIU) or equivalent function in a health plan, government agency, or large healthcare system.

Experience with compliance technology platforms and advanced data analytics for FWA detection.

Skills

Required :

Proven knowledge of CMS, DHCS, DMHC, OIG, and DOJ regulatory frameworks governing FWA programs.

Strong investigative skills, including evidence gathering, interviewing, and case documentation.

Demonstrated success in leading complex, multi-party investigations with integrity and discretion.

Excellent communication skills, with the ability to present investigative findings clearly to executives, boards, and regulators. Presented at NHCAA, HCCA or other professional organizational conferences.

Strong organizational and project management abilities; able to manage multiple investigations concurrently under tight deadlines.

Executive presence with ability to influence and build trust across the enterprise.

Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization.

Preferred :

Bilingual in one of L.A. Care Health Plan's threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.

Licenses / Certifications Required

Licenses / Certifications Preferred

And / Or any of the following Licenses / Certifications :

Certified Fraud Examiner (CFE)

Certified HealthCare Compliance (CHC)

Certified Internal Auditor (CIA)

Certified Coder, RN, MD, PharmaD, or equivalent

Required Training

Physical Requirements

Light

Additional Information

Salary Range Disclaimer : The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

L.A. Care offers a wide range of benefits including :

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)