Director, Fraud Waste & Abuse

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy.AZ Blue offersa variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:

• Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week

• Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week

• Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month

• Onsite: daily onsite requirement based on the essential functions of the job

• Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building

Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.

This position requires work and residency within the state of Arizona.

PURPOSE OF THE JOB

As the Director of Fraud, Waste & Abuse, you will lead enterprise-wide initiatives to identify, investigate, and prevent fraudulent activity across the health plan's provider and claims networks. This key leadership role is vital to maintaining regulatory compliance, ensuring responsible stewardship of healthcare dollars, and preserving the integrity of the organization's mission to deliver value-based, member-centered care.

This position oversees strategic and operational components of the Fraud, Waste and Abuse program-including analytics, internal investigations, and provider audits-aligned with CMS and state Medicaid guidelines.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

1. Required Work Experience

* 7 years of progressively responsible experience managing healthcare FWA investigations.

* 3 years experience in a management role.

* In-depth knowledge of CMS and state Medicaid FWA guidance for managed care organizations.

* Demonstrated expertise in leading cross-departmental FWA initiatives within a payer environment.

2. Required Education

* Bachelor's degree required in healthcare, finance, criminal justice, business, or a related field.

3. Required Certifications

* Professional Certification(s) (e.g. CPA, CHC, CIA, AHFI) required

PREFERRED QUALIFICATIONS

1. Required Work Experience

* 10 years of progressively responsible experience managing healthcare FWA investigations.

* 5 years in a management role.

* In-depth knowledge of CMS and state Medicaid FWA guidance for managed care organizations.

* Demonstrated expertise in leading cross-departmental FWA initiatives within a payer environment.

2. Required Education

* Bachelor's degree required in healthcare, finance, criminal justice, business, or a related field.

* Advanced degree (e.g., JD, MPH, MBA) preferred.

3. Required Certifications

* Certifications such as Certified Fraud Examiner (CFE), Certified in Healthcare Compliance (CHC), or Certified Professional Coder (CPC) strongly preferred.

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

Operational Leadership

* Direct the day-to-day operations of the FWA Division, including oversight of data mining activities, fraud tip triage, special investigations, and complex provider audits.

* Lead the Special Investigations Unit (SIU) in detecting and investigating suspected FWA in claims, billing, provider behavior, member activity, and internal operations.

* Champion a data-driven culture focused on proactive detection and risk mitigation.

Regulatory Compliance

* Ensure strict adherence to all applicable federal and state healthcare fraud regulations, including CMS rules for Medicare Advantage and Medicaid plans.

* Lead responses to FWA-related audits, inquiries, or corrective actions.

* Maintain and continuously improve FWA-related policies, procedures, training, and reporting protocols.

* Ensure adherence to all federal and state regulatory requirements including CMS Chapter 9/21 (Medicare), Medicaid MCO contracts, and NAIC model laws.

* Prepare and submit required regulatory reports (e.g., SIU annual reports, referrals to CMS, OIG, state agencies).

Cross-Functional Collaboration

* Partner with Claims, Provider Relations, Legal, and IT to refine payment accuracy strategies.

* Manage external vendor relationships and contracts related to FWA functions.

* Design and deploy strategies that integrate advanced data analytics, predictive modeling, and AI to improve identification of FWA patterns.

Strategy & Innovation

* Stay abreast of industry trends and evolving fraud tactics, adapting program strategies accordingly.

* Develop, implement, and maintain a comprehensive FWA strategy aligned with regulatory requirements and enterprise risk management goals.

* Build cross-functional relationships with internal departments (claims, provider relations, medical management, compliance, legal, IT) to ensure integration of FWA controls.

* Collaborate with external partners such as state Medicaid Fraud Control Units (MFCUs), FBI, CMS, OIG, and national fraud task forces.

* Educate internal teams on FWA red flags, protocols, and response procedures.

* Develop key performance indicators (KPIs) and operational dashboards to measure program effectiveness.

* Report FWA trends, risk areas, and outcomes to senior leadership, compliance committees, and the board as needed.

COMPETENCIES

REQUIRED COMPETENCIES

1. Required Job Skills

* Exceptional analytical acumen and experience with fraud detection tools and data platforms

* Proven leadership in high-stakes investigative or regulatory environments

* Excellent verbal and written communication; persuasive with both technical and executive stakeholders

* Experience overseeing a health plan's SIU or FWA program

* Background in value-based care or population health initiatives

* Familiarity with payment integrity platforms, NLP, or machine learning tools

* Must have experience in Governmental Investigations (MA, MAPD, PDP, HCR, Medicaid), and a thorough understanding of regulatory issues and laws.

* Firsthand trial and deposition experience required.

* Competency in strategic planning, training, negotiation, facilitation, and project development.

* Work history must demonstrate the use of tenacity to pursue difficult and sensitive issues to an acceptable conclusion.

* Excellent oral and written communication skills, excellent organizational skills, and excellent people skills required.

* Working knowledge of relevant software. Incumbent must maintain complete confidentiality of information encountered and trust of the Company and staff in all matters under their control.

Our Commitment

AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.

Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.