About this role
<p><b>Salary Range: </b> $135,136.00 (Min.) - $175,676.00 (Mid.) - $216,218.00 (Max.)</p> <p> </p> <p>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br> <br> Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br> </p> <div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px">Job Summary</H2> </div><div><p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">The Director, Compliance on Special Investigations and Fraud, Waste and Abuse (FWA) 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. </span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">The Director provides strategic direction, operational leadership, and subject matter expertise to safeguard L.A. Care’s integrity, protect member trust, and mitigate financial and reputational risks. This position leads investigative governance across the enterprise, coordinating with internal stakeholders and external regulators to ensure timely, thorough, and effective resolution of investigative matters. </span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.</span></span></p> </div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px">Duties</H2> </div><div><p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif"><b>Leadership and Program Oversight:</b></span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Lead L.A. Care’s Special Investigations Unit (SIU) in overseeing the internal and external investigations into fraud, waste, abuse, and compliance violations. </span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">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. </span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Ensure effective case intake, triage, investigation, tracking, and resolution processes, including referral to law enforcement, regulators, or external entities as needed. </span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Develop and support enterprise policies, procedures, and training programs supporting FWA prevention, detection, and response.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif"><b>Investigations and Regulatory Engagement: </b></span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Direct and oversee investigations into allegations of non-compliance, ethical violations, or fraudulent behavior involving employees, delegated entities, providers, or vendors.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Partner with Legal, Compliance, and Human Resources on sensitive internal investigations to ensure confidentiality, integrity, and fairness.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Ensure timely and accurate reporting of SIU/FWA activity to external agencies to meet regulatory requirements.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Lead enterprise readiness for external audits, regulatory inquiries, and enforcement actions involving SIU and FWA matters. </span></span></p> <p> </p> <p> </p> </div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px">Duties Continued</H2> </div><div><p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif"><b>Risk Management and Oversight</b></span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Conducts strategic planning to use resources to meet current and future departmental and Enterprise-wide goals.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Monitor investigative trends, emerging risks, and regulatory developments to proactively adapt investigative strategy and resource allocation.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Develop dashboards, analytics, and reporting tools to provide executives and the Board with visibility into investigative outcomes, financial recoveries, and risk trends.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Ensure alignment of investigative and FWA activities with organizational risk appetite, compliance strategy, and enterprise risk management frameworks.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif"><b>Collaboration and Culture:</b></span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Serve as a trusted advisor and subject matter expert to senior leadership, the Compliance Committee, and the Audit Committee on investigative matters.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Collaborate with cross-functional leaders to embed FWA prevention and detection mechanisms across operations.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Champion a culture of integrity, accountability, and transparency by promoting awareness of FWA risks and prevention strategies.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">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.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Manages budgets and resources effectively.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:'Calibri', sans-serif">Perform other duties as assigned.</span></span></p> </div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px">Education Required</H2> </div><div><div>Bachelor's Degree in Criminal Justice or Related Field</div><div>In lieu of degree, equivalent education and/or experience may be considered.</div></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px">Education Preferred</H2> </div><div><div>Master's Degree in Public Policy or Related Field</div></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px">Experience</H2> </div><div><p style="margin-bottom:2.0px;margin-top:2.0px"><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif"><b>Required:</b></span></span></p> <p style="margin-bottom:2.0px;margin-top:2.0px"><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">At least 7 years of experience in healthcare compliance, fraud investigations, law enforcement, or related field.</span></span></p> <p style="margin-bottom:2.0px;margin-top:2.0px"><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">At least 5years of experience in leading teams, projects, initiatives, or cross-functional groups.</span></span></p> <p style="margin-bottom:2.0px;margin-top:2.0px"><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Demonstrated experience managing complex investigations in a managed care or healthcare environment. </span></span></p> <p style="margin-bottom:2.0px;margin-top:2.0px"><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Experience in coordinating with external regulators and law enforcement agencies. </span></span></p> <p style="margin-bottom:2.0px;margin-top:2.0px"> </p> <p style="margin-bottom:2.0px;margin-top:2.0px"><span style="font-size:10.0pt"><span><span style="font-family:Calibri, sans-serif"><b>Preferred:</b></span></span></span></p> <p style="margin-bottom:2.0px;margin-top:2.0px"><span style="font-size:10.0pt"><span><span style="font-family:Calibri, sans-serif">Prior leadership of a Special Investigations Unit (SIU) or equivalent function in a health plan, government agency, or large healthcare system.</span></span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:'Calibri', sans-serif">Experience with compliance technology platforms and advanced data analytics for FWA detection.</span></span></p> </div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px">Skills</H2> </div><div><p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif"><b>Required:</b></span></span></p> <p style="margin-bottom:2.0px;margin-top:2.0px"><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Proven knowledge of CMS, DHCS, DMHC, OIG, and DOJ regulatory frameworks governing FWA programs</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Strong investigative skills, including evidence gathering, interviewing, and case documentation. </span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Demonstrated success in leading complex, multi-party investigations with integrity and discretion.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Excellent communication skills, with the ability to present investigative findings clearly to executives, boards, and regulators. Presented at NHCAA, HCCA or other professional organizational conferences</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Strong organizational and project management abilities; able to manage multiple investigations concurrently under tight deadlines.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Executive presence with ability to influence and build trust across the enterprise.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization.</span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif"><b>Preferred:</b></span></span></p> <p><span style="font-size:10.0pt"><span style="font-family:Calibri, sans-serif">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 </span></span></p> </div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px">Licenses/Certifications Required</H2> </div><div></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px">Licenses/Certifications Preferred</H2> </div><div><div>And/Or any of the following Licenses/ Certifications:</div><div>Certified Fraud Examiner (CFE)</div><div>Certified HealthCare Compliance (CHC)</div><div>Certified Internal Auditor (CIA)</div><div>Certified Coder, RN, MD, PharmaD, or equivalent</div></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px">Required Training</H2> </div><div></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px">Physical Requirements</H2> </div><div><div>Light</div></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px">Additional Information</H2> </div><div></div></div></div><p><b>Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.</p> <p> </p> <p><b>L.A. Care offers a wide range of benefits including</b></p> <ul> <li>Paid Time Off (PTO)</li> <li>Tuition Reimbursement</li> <li>Retirement Plans</li> <li>Medical, Dental and Vision</li> <li>Wellness Program</li> <li>Volunteer Time Off (VTO)</li> </ul> <p> </p>