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 begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes:

• Employer sponsored health, dental and vision plan with low or no premium

• Generous paid time off

• $100 monthly mobile or internet stipend

• Stock options for all employees

• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles

• Parental leave program

• 401K program

• And more....

*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.

Healthcare equality is at the center of Devoted’s mission to treat our members like family. We are committed to a diverse and vibrant workforce.

At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States. And we've just started. So join us on this mission!

Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.

As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.