Fraud Detection and Response Lead

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Public Partnerships LLC supports individuals with disabilities or chronic illnesses and aging adults, to remain in their homes and communities and "self" direct their own long-term home care. Our role as the nation's largest and most experienced Financial Management Service provider is to assist those eligible Medicaid recipients to choose and pay for their own support workers and services within their state-approved personalized budget. We are appointed by states and managed healthcare organizations to better serve more of their residents and members requiring long-term care and ensure the efficient use of taxpayer funded services.

Our culture attracts and rewards people who are results-oriented and strive to exceed customer expectations. We desire motivated candidates who are excited to join our fast-paced, entrepreneurial environment, and who want to make a difference in helping transform the lives of the consumers we serve. (learn more at www.pplfirst.com ).

Position Summary :

We are seeking a highly analytical and experienced Fraud Detection & Response Manager to oversee our healthcare fraud prevention efforts. This role is critical in identifying, investigating, and responding to fraudulent activities across clinical, operational, billing, and digital platforms. The ideal candidate will combine strong investigative skills with a deep understanding of healthcare operations, regulatory compliance, and data analytics to proactively detect and respond to fraudulent activities.

Key Responsibilities :

• Investigate internal threats, including employee misuse, insider fraud, and privileged account abuse across healthcare and financial systems.
• Collaborate with third-party forensic and analytics firms (e.g., Kroll) to deploy predictive analytics for early fraud detection and risk scoring.
• Utilize industry-recognized fraud detection platforms (e.g., ThreatMetrix, NICE Actimize, SAS Fraud Framework, Feedzai) to analyze anomalies and manage alerts.
• Lead investigations into payroll and payment fraud schemes such as direct deposit manipulation, ghost employees, and unauthorized wire transfers.
• Apply fraud detection strategies to both healthcare and financial / FinTech ecosystems, including digital payment platforms and financial transaction systems.
• Monitor and investigate suspicious patterns in application logs, including authentication attempts, API calls, and financial transaction anomalies.
• Collaborate with cybersecurity teams to address fraud risks in cloud-based financial applications and cross-channel payment infrastructure.
• Leverage financial fraud typologies such as account takeover, synthetic identity fraud, ACH / wire fraud, and social engineering.
• Engage with card processors, FinTech vendors, and fraud consortia to identify emerging threats and coordinate fraud mitigation strategies.
• Lead the design, development, and execution of fraud detection and monitoring programs across claims, billing, EHR systems, and other healthcare processes.
• Utilize data analytics, machine learning, and behavior modeling tools to identify suspicious activities, anomalies, and fraud indicators.
• Conduct investigations into suspected internal and external fraud, including patient identity theft, billing fraud, and prescription or provider fraud.
• Collaborate with compliance, legal, IT, and internal audit teams to manage fraud incidents, ensuring proper documentation, escalation, and resolution.
• Develop fraud response strategies, including containment, reporting, and remediation plans.
• Work with cybersecurity teams to identify fraud vectors involving digital systems (e.g., patient portals, payment platforms, or medical device tampering).
• Prepare detailed reports and dashboards on fraud trends, investigation outcomes, and risk mitigation efforts for senior leadership and regulatory bodies.
• Partner with third-party vendors, law enforcement, and regulatory agencies as needed for investigations or legal actions.
• Support the organization's compliance with HIPAA, HITECH, CMS, and state regulations as they pertain to fraud and abuse.
• Lead and mentor a small team of fraud analysts, investigators, or data scientists (if applicable).
• Contribute to staff training, awareness campaigns, and policy development to strengthen fraud prevention culture.

Qualifications :

Education & Experience :

Certifications (preferred) :

Skills and Competencies :

Why Join Us :

Salary : $135,000- $150,000

The above is intended to describe the general contents and requirements of work being performed by people assigned to this classification. It is not intended to be construed as an exhaustive statement of all duties, responsibilities, or skills of personnel so classified.

This position may have access to private, confidential or sensitive information related to PPL, its customers or clients, or patient information. Employees in this position are required to complete new hire and annual training for privacy and security, complete attestations for the PPL Code of Conduct, The Employee Handbook, and satisfactorily pass a background screen before access to any PPL information will be granted.

PPL is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion. We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences. At PPL, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications. We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and / or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law. PPL will not tolerate discrimination or harassment based on any of these characteristics.

If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!