Director, Special Investigations Unit (SIU)

Job Description

A bit about this role: 

As the Director, Special Investigations Unit (SIU), you will provide strategic and tactical management of Devoted Health’s SIU, driving significant impact on key departmental functions and company results. You will be responsible for implementing and sustaining a highly coordinated, cross-functional program integrity framework, with the SIU focusing on fraud investigations and ensuring regulatory compliance. This role requires a strong focus on accountability and leadership for program results, which requires the ability to clearly convey objectives and priorities to the team, and building strong partnerships outside of the SIU as program success requires cross functional collaboration and execution.

Your Responsibilities and Impact will include:

• Drive the strategy and results of the FWA program, continuously monitoring performance and proactively stepping into solution mode if key performance indicators (KPIs) indicate improvement opportunities or when issues arise.

• Lead the Annual FWA Risk Assessment and workplan development, ensuring quarterly review and updates are conducted in response to internal trends, as well as supported by a quarterly review of external and industry sources to reflect the evolving fraud risk landscape.  

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

• Develop, implement and maintain comprehensive SIU policies, standard operating procedures (SOPs) and training, including but not limited to regulatory compliance requirements, referral triage, case/inventory management,  investigations, and quality assurance processes.

• Manage team performance and provide day-to-day leadership in accordance with KPIs. This includes reviewing and approving Preliminary Investigation Reports, Final Investigations Reports, and Corrective Action Plans (CAPs).

• Partner closely with Payment Integrity, Claims, Delegated Operations, Pharmacy Operations, Utilization Management, Compliance, Legal, vendor partners, and other stakeholders to develop and implement strategies to prevent, detect and correct potential fraud.

• Serve as Chair of the Fraud, Waste and Abuse Sub-Committee which supports the Chief Compliance Officer in monitoring the overall FWA program integrity and effectiveness. 

• Work closely with state and federal program integrity organizations, including Medicaid Fraud Control Units (MFCU), CMS i-MEDIC, or other agencies in representing Devoted Health.

• Represent Devoted Health at State Fraud Task Force Meetings or other industry group meetings (i.e., NHCAA, HCCA).
   

Required skills and experience:

• At least 7 years of experience in healthcare compliance, fraud investigations, law enforcement, or related field, with at least 5 years of experience as a FWA program leader, responsible for oversight and management of a health plan’s SIU and FWA program. 

• Proven knowledge of CMS, OIG, and DOJ regulatory frameworks governing FWA programs.

• Strong investigative skills, with broad fraud investigative experience,  including evidence gathering, interviewing, and case documentation, with demonstrated success in leading complex, multi-party investigations with integrity and discretion. 

• Excellent communication skills, with the ability to present investigative findings clearly to executives, boards, and regulators. 

• Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization.

• Strong program management abilities with demonstrated competency in strategic planning, training development, and project management.

• Licenses / Certifications Preferred: Certified Fraud Examiner (CFE), Certified Healthcare Compliance (CHC).

Desired skills and experience:

• Prior experience in a law enforcement investigative role, demonstrating advanced skills in complex case development, evidence preservation, and effective witness/suspect interviewing.

#LI-DS1
#LI-Remote

Salary range: $164,000 - $200,000 annually

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process beg