What are the responsibilities and job description for the Director, Fraud Detection & Prevention position at mtminc?
What will your job look like? The Director, Fraud Detection & Prevention plays a critical leadership role in driving the organization’s strategy to identify, mitigate, and address instances of fraud, inefficiency, and abuse. This position leads the Special Investigations Unit (SIU), oversees high-level investigations, and ensures adherence to all applicable federal and state regulations, including those governing Medicare and Medicaid programs. Location: Must reside in the St. Louis, MO area. This is a hybrid role of work from home and in office work at our Lake St. Louis, MO office location. What you’ll do: 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 What you’ll need: Experience, Education & Certifications: 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 Skills: 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 Demonstrate 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 Even better if you have... Master’s degree in a related field a plus Professional certifications such as CFE (Certified Fraud Examiner), CIA, or similar strongly preferred What’s in it for you: 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 Equal Opportunity Employer: MTM is an equal opportunity employer. MTM considers qualified candidates with a criminal history in a manner consistent with the requirements of applicable local, State, and Federal law. If you are in need of accommodations, please contact MTM’s People & Culture. #MTM We invite you to apply for any of our open positions and look forward to providing you an opportunity to develop your career as a member of our team.
