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L.A. Care Health Plan · 16 hours ago

Director, Compliance on Special Investigations Unit and Fraud, Waste and Abuse

Los Angeles, CA

Full-time

Onsite

Director/Executive

$135K/yr - $216K/yr

7+ years exp

L.A. Care Health Plan is the nation’s largest publicly operated health plan, providing health coverage to low-income Los Angeles County residents. The Director, Compliance on Special Investigations Unit and Fraud, Waste and Abuse is responsible for overseeing investigations into misconduct and ensuring compliance with regulatory requirements while leading the Special Investigations Unit and FWA program.

FitnessGovernmentHealth Care

Responsibilities

Lead L.A. Care’s Special Investigations Unit (SIU) in overseeing the 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, ensuring compliance with Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS), and state/federal requirements

Ensure effective case intake, triage, investigation, tracking, and resolution processes, including referral to law enforcement, regulators, or external entities as needed

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 involving employees, delegated entities, providers, or vendors

Partner with Legal, Compliance, and Human Resources on sensitive internal investigations to ensure confidentiality, integrity, and fairness

Ensure timely and accurate reporting of SIU/FWA activity to external agencies to meet regulatory requirements

Lead enterprise readiness for external audits, regulatory inquiries, and enforcement actions involving SIU and FWA matters

Conducts strategic planning to use resources to meet current and future departmental and Enterprise-wide goals

Monitor investigative trends, emerging risks, and regulatory developments to proactively adapt investigative strategy and resource allocation

Develop dashboards, analytics, and reporting tools to provide executives and the Board with visibility into investigative outcomes, financial recoveries, and risk trends

Ensure alignment of investigative and FWA activities with organizational risk appetite, compliance strategy, and enterprise risk management frameworks

Serve as a trusted advisor and subject matter expert to senior leadership, the Compliance Committee, and the Audit Committee on investigative matters

Collaborate with cross-functional leaders to embed FWA prevention and detection mechanisms across operations

Champion a culture of integrity, accountability, and transparency by promoting awareness of FWA risks and prevention strategies

Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees

Manages budgets and resources effectively

Perform other duties as assigned

Qualification

Healthcare complianceFraud investigationsRegulatory frameworksInvestigative skillsData analyticsProject managementTeam leadershipExecutive presenceBilingualCertified Fraud ExaminerCertified HealthCare ComplianceCertified Internal AuditorCommunication skillsOrganizational skills

Required

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, with the ability to present investigative findings clearly to executives, boards, and regulators

Strong organizational and project management abilities; able to manage multiple investigations concurrently under tight deadlines

Executive presence with ability to influence and build trust across the enterprise

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

And/Or Any Of The Following Licenses/ Certifications: Certified Fraud Examiner (CFE), Certified HealthCare Compliance (CHC), Certified Internal Auditor (CIA), Certified Coder, RN, MD, PharmaD, or equivalent

Preferred

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 is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese