Director, Fraud Prevention and Program Oversight

POSITION SUMMARY /RESPONSIBILITIES

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.