Director, Fraud Detection & Prevention

What will your job look like?

The Director, Fraud Detection & Prevention plays a critical leadership role in driving the organization’s strategy to identify, mitigate, and address instances of fraud, inefficiency, and abuse.

This position leads the Special Investigations Unit (SIU), oversees high-level investigations, and ensures adherence to all applicable federal and state regulations, including those governing Medicare and Medicaid programs.

Location: Must reside in the St.

Louis, MO area.

This is a hybrid role of work from home and in office work at our Lake St.

Louis, MO office location.

What you’ll do:


* Develop and implement a comprehensive FWA prevention and detection program across the organization


* Lead investigations into suspected fraud, waste, or abuse, ensuring timely resolution and appropriate corrective actions


* Draft, revise, and enforce FWA-related policies and procedures


* Design and deliver targeted training programs for high-risk departments and roles


* Develop dashboards and KPIs to monitor FWA trends and program effectiveness


* Leverage predictive analytics, AI tools, and forensic software to proactively detect anomalies and suspicious patterns


* Establish and maintain reporting mechanisms for suspected FWA, including anonymous hotlines and digital platforms


* Monitor industry trends, regulatory changes, and geopolitical risks that may impact FWA exposure


* Conduct risk assessments and data analytics to identify patterns and vulnerabilities


* Oversee training and awareness programs to educate employees on FWA policies and ethical conduct


* Prepare detailed reports for executive leadership


* Ensure compliance with federal, state, and industry-specific regulations (e.g., HIPAA, CMS, DOJ guidelines)


* Monitor emerging threats and trends in fraud and abuse, adapting strategies accordingly


* Other duties as assigned

What you’ll need:

Experience, Education & Certifications:


* Bachelor’s degree required, preferably in a business-related field


* 7–10 years of experience in healthcare fraud investigations or regulatory compliance


* Experience with case management systems, forensic tools, and data analytics platforms


* Experience managing cross-functional teams and external audits

Skills:


* Excellent organizational skills


* Ability to multi-task and set priorities in a fast-paced environment


* Ability to handle confidential information in a professional manner


* Ability to make solid judgment calls


* Conduct all activities in an organized, timely and responsible manner


* Ability to gain and maintain knowledge of all department responsibilities preferred


* Proficiency with MS Office Suite


* Demonstrate excellent time management skills


* Ability to work within a team-oriented environment


* Ability to identify, interpret and communicate business risks


* Ability to lead, coa...