Director, Fraud Detection & Prevention en 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.

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