Director, Fraud Waste & Abuse

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:

• Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week

• Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week

• Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month

• Onsite: daily onsite requirement based on the essential functions of the job

• Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building

Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.

This position requires work and residency within the state of Arizona.

PURPOSE OF THE JOB

As the Director of Fraud, Waste & Abuse, you will lead enterprise-wide initiatives to identify, investigate, and prevent fraudulent activity across the health plan’s provider and claims networks. This key leadership role is vital to maintaining regulatory compliance, ensuring responsible stewardship of healthcare dollars, and preserving the integrity of the organization’s mission to deliver value-based, member-centered care.

This position oversees strategic and operational components of the Fraud, Waste and Abuse program—including analytics, internal investigations, and provider audits—aligned with CMS and state Medicaid guidelines.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

1. Required Work Experience

· 7 years of progressively responsible experience managing healthcare FWA investigations.

· 3 years experience in a management role.

· In-depth knowledge of CMS and state Medicaid FWA guidance for managed care organizations.

· Demonstrated expertise in leading cross-departmental FWA initiatives within a payer environment.

2. Required Education

· Bachelor's degree required in healthcare, finance, criminal justice, business, or a related field.

3. Required Certifications

· Professional Certification(s) (e.g. CPA, CHC, CIA, AHFI) required

PREFERRED QUALIFICATIONS

1. Required Work Experience

· 10 years of progressively responsible experience managing healthcare FWA investigations.

· 5 years in a management role.

· In-depth knowledge of CMS and state Medicaid FWA guidance for managed care organizations.

· Demonstrated expertise in leading cross-departmental FWA initiatives within a payer environment.

2. Required Education

· Bachelor's degree required in healthcare, finance, criminal justice, business, or a related field.

· Advanced degree (e.g., JD, MPH, MBA) preferred.

3. Required Certifications

· Certifications such as Certified Fraud Examiner (CFE), Certified in Healthcare Compliance (CHC), or Certified Professional Coder (CPC) strongly preferred.

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

Operational Leadership

· Direct the day-to-day operations of the FWA Division, including oversight of data mining activities, fraud tip triage, special investigations, and complex provider audits.

· Lead the Special Investigations Unit (SIU) in detecting and investigating suspected FWA in claims, billing, provider behavior, member activity, and internal operations.

· Champion a data-driven culture focused on proactive detection and risk mitigation.

Regulatory Compliance

· Ensure strict adherence to all applicable federal and state healthcare fraud regulations, including CMS rules for Medicare Advantage and Medicaid plans.

· Lead responses to FWA-related audits, inquiries, or corrective actions.

· Maintain and continuously improve FWA-related policies, procedures, training, and reporting protocols.

· Ensure adherence to all feder