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L.A. Care Health Plan Logo L.A. Care Health Plan · Finance

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

United States, Los Angeles 135136.00 - 216218.00 USD / Year · Job Posted January 01, 2026

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Job Description

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.

Job Responsibility

  • Lead L.A. Care’s Special Investigations Unit (SIU) in overseeing 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
  • Ensure effective case intake, triage, investigation, tracking, and resolution processes
  • Develop and support enterprise policies, procedures, and training programs supporting FWA prevention, detection, and response
  • Direct and oversee investigations into allegations of non-compliance, ethical violations, or fraudulent behavior
  • Partner with Legal, Compliance, and Human Resources on sensitive internal investigations
  • Ensure timely and accurate reporting of SIU/FWA activity to external agencies
  • Lead enterprise readiness for external audits, regulatory inquiries, and enforcement actions
  • Conduct strategic planning to use resources to meet departmental and Enterprise-wide goals
  • Monitor investigative trends, emerging risks, and regulatory developments
  • Develop dashboards, analytics, and reporting tools
  • Serve as a trusted advisor and subject matter expert to senior leadership
  • Collaborate with cross-functional leaders to embed FWA prevention and detection mechanisms
  • Champion a culture of integrity, accountability, and transparency
  • Develops goals, objectives and actions plans for assigned staff
  • Manages budgets and resources effectively

Requirements

  • Bachelor's Degree in Criminal Justice or Related Field
  • 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
  • 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
  • Strong organizational and project management abilities
  • Executive presence with ability to influence and build trust across the enterprise
  • Demonstrated ability to think long-term and develop strategies
  • Certified Fraud Examiner (CFE) or Certified HealthCare Compliance (CHC) or Certified Internal Auditor (CIA) or Certified Coder, RN, MD, PharmaD, or equivalent

Nice to have

  • Master's Degree in Public Policy or Related Field
  • 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
  • Bilingual in one of L.A. Care Health Plan’s threshold languages (English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese)

What we offer

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)
L.A. Care Health Plan - All Job Offers

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