Director, Fraud Prevention and Program Oversight

University Health; San Antonio (TX); On-site; USD 150,000 - 210,000; Full time

Job summary

Community First Health Plans, Inc. in Texas seeks a Director, Fraud Prevention and Program Oversight to lead anti-fraud efforts across Medicaid, CHIP, Medicare, Marketplace and Commercial lines.

You will set enterprise standards, strengthen internal controls, and oversee SIU operations, payment integrity analytics, and vendor oversight. The role requires a Bachelor’s degree in accounting or related field, with at least three years of audit and supervisory experience; experience with SOX/NAIC MAR

Qualifications

• Bachelor's degree in accounting, business administration or related field.
• Experience with anti-fraud detection and prevention is required.
• Three years of supervisory experience is preferred.
• Experience with SEC SOX and NAIC MAR audits, and ERM is highly desirable.
• At least three years of professional audit experience is required.

Responsibilities

• Lead the organization’s fraud prevention, detection, investigation, and remediation efforts across all product lines.
• Set enterprise standards, strengthen internal controls, and oversee SIU operations, payment integrity analytics and vendor oversight.
• Oversee internal auditing functions to ensure program integrity and regulatory compliance.

Skills

Audit experience

SOX & NAIC MAR audits

Regulatory interpretation

Supervisory experience

Enterprise Risk Management (ERM)

Education

Bachelor's degree in accounting, business administration or related field

Job description

Director, Fraud Prevention and Program Oversight

Community First Health Plans, Inc. (Community First) is an HMO providing health care services to Medicaid and CHIP, Medicare, Marketplace, and Commercial recipients. Community First must ensure that all operations are aligned with the regulatory requirements of the Texas Health and Human Services Commission (HHSC), the Texas Department of Insurance (TDI), the Centers for Medicare and Medicaid Services (CMS), and the National Association of Insurance Commissioners (NAIC). The Fraud Prevention and Program Oversight Director leads the organization’s efforts to prevent, detect, investigate, and remediate fraud, waste, and abuse (FWA) across all product lines. The role ensures program integrity by setting organizational standards, strengthening internal controls, and overseeing the Special Investigations Unit (SIU) operations, payment integrity analytics, and vendor oversight. The role ensures program integrity by setting enterprise standards, strengthening internal controls, and overseeing SIU operations, payment integrity analytics, vendor oversight, and internal auditing functions.

EDUCATION/EXPERIENCE

Bachelor’s degree is required in accounting, business administration or related field. Experience in interpretation of regulatory agency policies is preferred. Experience with anti-fraud detection and prevention is required. Three years of supervisory experience is preferred. Experience with SEC SOX and/or NAIC MAR audits, and Enterprise Risk Management (ERM) is highly desirable. At least three years of professional audit experience is required.