The Director, Compliance on Special Investigations Unit and Fraud, Waste and Abuse is responsible for directing L.A. Care Health Plan’s enterprise special investigations unit (SIU) and FWA program. The Director oversees internal and external investigations into potential misconduct, regulatory violations, and fraudulent activity while ensuring compliance with federal and state regulatory requirements.
Requirements
- 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.
- 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.
Benefits
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
