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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)