Dir Special Investigations Uni

Role Overview:

The Director, Special Investigations Unit (SIU) provides enterprise leadership for the prevention, detection, investigation, remediation, and reporting of healthcare fraud, waste, and abuse across Medicaid, Medicare, pharmacy, behavioral health, dental, transportation, and other products and services. The role requires a leader who can adapt to the rapidly transforming healthcare compliance landscape by leveraging data analytics, AI assisted fraud detection, as permitted by regulatory and contractual requirements, and cross-functional collaboration to prevent, detect and address fraud, waste, and abuse. The Director establishes SIU strategy, governance, and operating standards; leads managers and investigative professionals; and ensures investigations are timely, well documented, legally supportable, and compliant with federal and state requirements and contractual obligations. The Director partners with Legal, Finance, Clinical, Network, Claims, Data Analytics, market leadership, and external agencies to address emerging risks, strengthen program integrity, recover overpayments, and prevent future losses. The role oversees case intake, triage, analytics, investigations, referrals, recoveries, audit readiness, and performance reporting, and represents the organization and/or supports the Chief Compliance & Privacy Officer, Market Compliance Directors and/or Market Leadership with regulators, law enforcement, and program integrity partners. This role reports to the Chief Compliance & Privacy Officer and sits within the Compliance Program.

Work Arrangement:

- Remote within the United States, working Eastern Standard Time. There is a 25% travel expectation within the Markets.

Responsibilities:

- Sets SIU strategy and governance for enterprise fraud, waste, and abuse prevention, detection, investigation, remediation, pre-payment cost avoidance, recovery, and referral activities; aligns priorities with regulatory, contractual, and business requirements and delivers on Market and Enterprise expectations.
- Leads and develops SIU leadership and investigative teams by establishing SMART goals, allocating resources, managing performance, building capability, and maintaining consistent investigative quality across markets and products in a manner that meets regulatory, market and enterprise expectations of fairness and compliance
- Oversees the end-to-end case lifecycle, including intake, triage, assignment, investigative strategy, evidence development, quality review, disposition, referral, pre-payment cost avoidance, recovery, closure, and case-management documentation.
- Directs analytics and surveillance activities using claims data, fraud-detection tools, sampling methodologies, trend analysis, and internal and vendor intelligence to identify aberrant patterns and prioritize high-risk matters and provides as requested and regularly scheduled updates to Compliance, Market and Enterprise Leadership teams.
- Ensures regulatory and contractual compliance with applicable federal and state program-integrity, reporting, referral, prepayment cost avoidance and recovery, record-retention, and audit requirements; maintains policies, procedures, controls, and audit-ready evidence.
- Builds cross-functional remediation and prevention plans with Compliance, Legal, Finance, Clinical, Claims, Network, Pharmacy, Operations, and market leadership to address root causes, reduce exposure, and strengthen controls.
- Leads pre-payment cost avoidance and overpayment recovery and settlement support, ensuring findings are well supported, pre-payment monitoring and cost avoidance and recovery actions are timely, and matters requiring legal review, litigation support, or negotiated resolution are properly coordinated.
- Represents the organization with external stakeholders, including state and federal agencies, Medicaid Fraud Control Units, law enforcement, regulators, auditors, and other program-integrity partners as requested.
- Provides executive reporting and committee leadership by timely communicating FWA trends, material cases, financial impact, operational performance, emerging risks, and recommended actions to senior leaders and governance bodies.
- Drives continuous improvement by monitoring performance indicators, investigation quality, cycle time, cost avoidance, recoveries, referral outcomes, and control effectiveness; implements training, technology, workflow, and policy enhancements.

Education & Experience:

- Bachelor’s Degree in criminal justice, healthcare administration, business, accounting, finance, law, compliance, data analytics, or a related field, required.
- Master’s Degree in business, healthcare administration, public administration, law, compliance, or a related field preferred.
- Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) required, or ability to obtain within 12 months of hire. Certified Insurance Fraud Investigator (CIFI), Certified in Healthcare Compliance (CHC), Certified Internal Auditor (CIA), or Certified Public Accountant (CPA) preferred.
- 10+ years of Healthcare fraud, waste, and abuse, SIU, program integrity, compliance, investigations, or related experience, including at least 5 years leading managers or investigative teams in a managed care, health plan, government program, or similarly regulated environment, required.
- Experience leading an enterprise or multi-market SIU function across Medicaid, Long Term Supports & Services, Medicare and/or Marketplace; exposure to pharmacy, behavioral health, dental, transportation, or other delegated services; and experience interacting with regulators, law enforcement, and program integrity agencies. Familiarity with artificial intelligence, machine learning, and project plans, preferred.

Skills & Competencies:

- Knowledge : Expert knowledge of healthcare fraud, waste, and abuse schemes; SIU and program-integrity requirements; Medicaid and Medicare regulations; managed care contracts; claims adjudication and reimbursement; overpayment recovery; investigative standards; evidence handling; interviewing; reporting and referral protocols; civil and criminal fraud concepts; and audit and record-retention expectations.
- Leadership : Demonstrated ability to set enterprise strategy, lead managers and geographically dispersed teams, establish performance measures, manage competing priorities, and drive consistent execution in a matrixed organization. Includes ability to present and influence stakeholders across the enterprise and markets.
- Analytics and technology : Strong ability to interpret claims and investigative data, identify aberrant billing patterns, evaluate sampling and data-mining results, and use case-management, fraud-detection, reporting, and Microsoft Office tools.
- Communication and influence : Executive-level written, verbal, presentation, negotiation, and stakeholder-management skills, with the ability to explain complex investigative and regulatory matters to varied audiences.
- Judgment and integrity : Sound decision-making, discretion, objectivity, and a high degree of integrity when handling sensitive, privileged, confidential, and personally identifiable information.
- Ability to partner with HR, Legal, Operational and Markets on joint investigation processes.
- External representation : Ability to build effective relationships with regulators, law enforcement, Medicaid Fraud Control Units, government program-integrity organizations, legal counsel, providers, vendors, and industry partners.
- Operational excellence : Ability to manage case quality, timeliness, pre-payment cost avoidance, recoveries, referrals, audit readiness, vendor performance, budgets, and continuous-improvement initiatives using measurable outcomes.

Our Comprehensive Benefits Package
Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents starting Day 1, 401(k) retirement savings plan, tuition reimbursement, and more.

Why Join Us: Your career starts now. We are looking for the next generation of healthcare leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. If you are driven to make a difference, we want to hear from you.

About AmeriHealth Caritas
Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. Our services include integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at http://www.amerihealthcaritas.com