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Director Fraud Remote Jobs (NOW HIRING)

Walmart

(USA) Director, Investigations

Bentonville, AR · On-site +1

This role reports to the Group Director, Enterprise Fraud Investigations and is responsible for ... manage remote investigators. * You are a self-starter with experience across multiple fraud ...

FICO

Senior Director/Director - AI Engineering

$192K - $302K/yr

... to enhance fraud detection, streamline decision authoring, automate customer communication ... RR1 #LI-remote Why Make a Move to FICO? At FICO, you can develop your career with a leading ...

Dyne Therapeutics

Director, Compliance

Waltham, MA · Remote

... care fraud and abuse laws, Value & Access matters, patient support programs, data privacy, and ... This role is based in Waltham, MA, without the possibility of being a remote role. Primary ...

OnPay

Director, Insurance Services

Atlanta, GA · On-site +1

$200K/yr

Remote flexibility: Work from anywhere in the U.S., or join our collaborative HQ team in Atlanta ... Recruiting Fraud Alert: To all candidates: your personal information and online safety are top of ...

Oscar Health

Associate Director, Tax

Boston, MA · Remote

$162K - $213K/yr

This is a remote position, open to candidates who reside in: Boston, MA. You will be fully remote ... Learn more about how you can safeguard yourself from recruitment fraud here. At Oscar, being an ...

Oscar Health

Associate Director, Tax

Atlanta, GA · Remote

$162K - $213K/yr

This is a remote position, open to candidates who reside in: Atlanta, GA. You will be fully remote ... Learn more about how you can safeguard yourself from recruitment fraud here. At Oscar, being an ...

Oscar Health

Associate Director, Tax

Dallas, TX · Remote

$162K - $213K/yr

This is a remote position, open to candidates who reside in: Dallas, TX. You will be fully remote ... Learn more about how you can safeguard yourself from recruitment fraud here. At Oscar, being an ...

Forhyre

Senior Director Marketing

New York, NY · Remote

EB5Visa Location: Remote / U.S. Based Type: Full-Time About EB5Visa.io We are building the ... Your work directly protects them from fraud and anxiety. Ground Floor Opportunity: As an early hire ...

Oscar Health

Associate Director, Tax

Hartford, CT · Remote

$180K - $236K/yr

This is a remote position, open to candidates who reside in: Hartford, CT. You will be fully remote ... Learn more about how you can safeguard yourself from recruitment fraud here. At Oscar, being an ...

Seon

Director of Engineering

Austin, TX · Remote

SEON is the command center for fraud prevention and AML compliance, helping thousands of companies ... Experience managing mostly remote teams in multiple timezones * Background of being a hands-on ...

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Director Fraud Remote information

What does a Director of Fraud (Remote) do?

A Director of Fraud (Remote) is responsible for overseeing and managing an organization's fraud prevention and detection programs while working remotely. They develop strategies to identify and mitigate fraudulent activities, lead teams of analysts or investigators, and ensure compliance with legal and regulatory standards. The role typically involves collaborating with other departments, implementing advanced technologies, and analyzing data to protect the company and its customers from financial loss due to fraud.

What is the difference between Director Fraud Remote vs Fraud Analyst Remote?

AspectDirector Fraud RemoteFraud Analyst Remote
Required CredentialsBachelor's degree, experience in fraud prevention, leadership skillsBachelor's degree, knowledge of fraud detection tools, analytical skills
Work EnvironmentStrategic oversight, team management, policy developmentData analysis, investigation, reporting
Employer & Industry UsageFinancial institutions, e-commerce, insuranceFinancial services, retail, online platforms

The main difference between a Director Fraud Remote and a Fraud Analyst Remote lies in their responsibilities and seniority. The Director focuses on strategic leadership, policy setting, and managing teams, while the Fraud Analyst handles day-to-day investigations and data analysis. Both roles require relevant experience and work in similar industries, but the Director role involves higher-level decision-making and oversight.

What are the key skills and qualifications needed to thrive as a Director of Fraud (Remote), and why are they important?

To thrive as a Director of Fraud (Remote), you need deep expertise in fraud detection and prevention, risk management, and data analysis, typically backed by a bachelor's or master's degree in finance, business, or a related field. Familiarity with fraud management platforms, data analytics tools like SQL or Python, and certifications such as CFE (Certified Fraud Examiner) are highly valued. Strong leadership, analytical thinking, and effective remote communication skills set top candidates apart in this role. These skills and qualities are crucial for protecting company assets, leading distributed teams, and implementing robust fraud prevention strategies in a remote environment.

What are some common challenges faced by a Director of Fraud working remotely, and how can they be addressed?

A Director of Fraud working remotely often faces challenges such as maintaining effective oversight of distributed teams, ensuring real-time communication during critical incidents, and keeping up with rapidly evolving fraud tactics. To address these, it's important to implement strong digital collaboration tools, schedule regular video meetings, and establish clear protocols for incident response. Additionally, fostering a culture of transparency and continuous learning helps remote teams stay agile and cohesive in combating fraud.
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What cities are hiring for Director Fraud Remote jobs? Cities with the most Director Fraud Remote job openings:
What states have the most Director Fraud Remote jobs? States with the most job openings for Director Fraud Remote jobs include:
What job categories do people searching Director Fraud Remote jobs look for? The top searched job categories for Director Fraud Remote jobs are:
Director Fraud Remote jobs near you
Infographic showing various Director Fraud Remote job openings in the United States as of May 2026, with employment types broken down into 5% As Needed, 63% Full Time, 11% Part Time, and 21% Contract. Highlights an 92% Physical, 3% Hybrid, and 5% Remote job distribution.

Clinical Auditor/Analyst (Remote)- Fraud, Waste and Abuse

UPMC Senior Communities

Pittsburgh, PA • On-site, Remote

$32.85 - $56.83/hr

Full-time

Posted 3 days ago

Job description

UPMC Health Plan has an exciting opportunity for a Clinical Auditor/Analyst position in the Fraud, Waste & Abuse department. This is a full time position working Monday through Friday daylight hours and will be a remote position.
The Clinical Auditor/Analyst is an integral part of the Special Investigations Unit (SIU) and is responsible for conducting clinical audits and reviews regarding the analysis of care and services related to clinical guidelines, coding requirements, regulatory requirements, and resource utilization. The Clinical Auditor/Analyst creates, maintains and analyzes auditing reports related to their assigned work plan and communicates the results with management. Other responsibilities include but are not limited to analysis of controlled substance prescribing and utilization to identify potential clinical care issues, prepayment review of claims, and prepayment review of unlisted codes. Claims analysis and the use of fraud and abuse detection software tools will be an integral part of the function of this position. Responsibilities will involve working in collaboration with appropriate Health Plan departments including Quality Improvement, Legal, and Medical Management to facilitate the resolution of issue or cases. Responsibilities may involve multiple line of business focused reviews, or ad hoc reviews as needed; analysis of billing by providers/physicians, and providing trending, analysis and reporting of auditing data. The Clinical Auditor/Analyst will routinely interact with providers, law enforcement and/or regulatory entities in the course of their duties.
Experience in mental health claims review and laboratory claims review is highly preferred!
Responsibilities:
  • Respond to fraud, waste, and abuse referrals and/or complete data analysis and related audits as assigned.
  • Utilize fraud detection software to assess and monitor for potential FWA.
  • Review and analyze claims, medical records and associated processes related to the appropriateness of coding, clinical care, documentation, and health plan business rules.
  • Provide a clinical opinion for special projects or various issues including appropriate utilization of controlled substances, prescribing of controlled substances, or medically appropriate services.
  • Query medical and/or pharmacy claims and conduct a risk assessment by performing data analysis and applying applicable coding guidelines,
  • Health Plan policies and any applicable National Coverage Determination (NCD) or Local Coverage Determination (LCD).Evaluate referrals from Pharmacy Benefit Manager (PBM) by analyzing medical and pharmacy claims and associated clinical documentation in HealthPlaNET, Mars, Epic and/or Cerner.
  • Complete audits by utilizing standard coding guidelines and principles and coding clinics to verify that the appropriate CPT codes/DRGs were assigned and supported in the medical record documentation.
  • Attend in person or virtual recipient restriction hearings.
  • Review Medical Pended Queue claims to understand and resolve claim referral issues through research and interaction with other Health Plan Departments including Medical Management, Medical Directors, various committees, and other appropriate Health Plan departments.
  • As necessary, assist in the development of new policies concerning future Health Plan payment of identified issue.
  • Assess, investigate and resolve low to intermediate issues.
  • Write concise written reports including statistical data for communication to other areas of UPMC Health Plan and to communicate with department heads for identification of various problem issues, how they affect the Health Plan, and to make recommendations for resolution of the issue.
  • Identify error trends to determine appropriate training needs and suggest modifications to company policies and procedures.
  • Conduct provider education, as necessary, regarding audit results.
  • Communicate effectively with Medical Directors and ancillary departments as necessary to address issues and concerns.
  • Understand customers including internal Health Plan Departments (i.e. Claims staff, Customer Service, Marketing, etc.) and external customers (i.e. Health System Internal Audit, Client Audit teams) to understand issues, identify solutions and facilitate resolution.
  • Serve as an SIU representative at internal and external meetings, document and present findings to SIU Staff and document as appropriate in the SIU FWA Case Management Database.
  • Assist in the development and revision of SIU policies and procedures.
  • Identify trends for improvements internally, such as claims payment, to determine appropriate training needs and suggest modification to company policies and procedures.
  • Participate in training programs to develop a thorough understanding of the materials presented.
  • Obtain CPE or CEUs to maintain nursing license, and/or professional designations.
  • Design and maintain reports, auditing tools and related documentation.
  • Maintain or exceed designated quality and production goals.
  • Maintain employee/insured confidentiality and adhere to HIPAA regulations.

Qualifications:
  • Registered Nurse (RN).
  • Five years of clinical experience.
  • Two years of fraud & abuse, auditing, case management, quality review or chart auditing experience required.
  • Ability to analyze data, maintain designated production standards, and organize multiple projects and tasks.
  • In-depth knowledge of medical terminology, ICD-10 and CPT-4 coding. Knowledge of health insurance products and various lines of business.
  • Detail-oriented individual with excellent organizational skills.
  • Keyboard dexterity and accuracy.
  • High level of oral and written communication skills.
  • Proficiency with Microsoft Office products (Excel, Access, OneDrive, OneNote and Word).
    Licensure, Certifications, and Clearances:
    AAPC or AHIMA Certified (CPC, CPMA, CIC, CCA, CCS, CCS-P) or AHFI designation preferred.
  • Registered Nurse (RN)

*Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.
UPMC is an Equal Opportunity Employer/Disability/Veteran

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