Hybrid Director, Fraud Detection – Prevention

at MTM, Inc.

• Job title: Director, Fraud Detection – Prevention
• Job type: Full Time
• Experience level: Lead
• Salary: Not specified
• Degree requirement: Bachelor's Degree
• Location requirements: Hybrid, St Louis, United States

About the role

• Director of Fraud Detection & Prevention leading fraud investigations in healthcare organization. Developing prevention programs and ensuring compliance with regulations while managing the Special Investigations Unit.

Responsibilities

• 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

Requirements

• 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
• 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
• Excellent time management skills
• Ability to work within a team-oriented environment
• Ability to identify, interpret and communicate business risks
• Ability to lead, coach and motivate a specialized compliance team
• Detail oriented, with excellent communication skills
• Data analysis and interpretation skills
• Ability to schedule, organize and prioritize multiple tasks
• Excellent problem-solving skills with the ability to anticipate and resolve problems
• Ability to maintain positive attitude and team focused during high stress situations
• Ability to maintain high level of confidentiality
• Strong understanding of Medicare, Medicaid, and commercial insurance programs
• Familiarity with whistleblower protections and internal control
• Deep understanding of regulatory frameworks and enforcement mechanisms
• Master’s degree in a related field a plus
• Professional certifications such as CFE (Certified Fraud Examiner), CIA, or similar strongly preferred.

Benefits

• Health and Life Insurance Plans
• Dental and Vision Plans
• 401(k) with a company match
• Paid Time Off and Holiday Pay
• Maternity/Paternity Leave
• Casual Dress Environment
• Tuition Reimbursement
• MTM Perks Discount Program
• Leadership Mentoring Opportunities