Job Description
It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a seasoned, strategic, and mission-driven Director to lead our Medicaid Fraud, Waste & Abuse (FWA) and Pharmacy Network Management functions. In this role, you will oversee program integrity operations, shape pharmacy network strategy, and lead high-performing teams dedicated to protecting Medicaid dollars while ensuring strong pharmacy access and provider accountability. The ideal candidate brings deep Medicaid expertise, exceptional people leadership skills, and a passion for building compliant, data-driven, and operationally excellent programs. This leader directs multidisciplinary operations teams, partners closely with state Medicaid agencies, ensures adherence to federal and state regulations, and drives initiatives that strengthen program integrity and enhance member access, provider performance, and overall network value. The Director is responsible for setting strategy, managing people and processes, and delivering measurable results across both domains. Your role in our mission Lead the vision, strategy, and execution of Medicaid FWA and pharmacy network management programs Drive initiatives that strengthen program integrity, optimize network performance, and meet state Medicaid expectations Monitor industry trends, regulatory changes, and emerging fraud schemes to proactively evolve program strategy Manage and develop managers, analysts, investigators, and network operations staff Build a collaborative, high-performance culture with clear goals, coaching, and professional growth opportunities Ensure teams operate with integrity, accountability, and operational excellence Oversee FWA detection, investigation, prevention, and reporting activities Guide the use of analytics, audits, and surveillance tools to identify high-risk providers and suspicious billing patterns Ensure timely case management, documentation, referrals, and corrective action plans Partner with state agencies, law enforcement, and internal compliance teams on FWA matters Direct the strategy, performance, and compliance of the Medicaid pharmacy network Oversee contracting, credentialing, reimbursement methodologies, and network adequacy Monitor pharmacy performance metrics and lead initiatives to improve access, quality, and cost-effectiveness Address high-risk pharmacy behavior and support provider education and engagement Serve as a primary liaison with state Medicaid agencies and regulatory bodies Ensure accurate and timely submission of required reports, audits, and corrective action plans Translate regulatory requirements into operational processes and team workflows Establish KPIs, dashboards, and reporting to track FWA outcomes and network performance Lead process improvements to enhance efficiency, accuracy, and compliance Oversee vendor relationships supporting FWA analytics, SIU functions, and credentialing Manage budgets, resource planning, and ROI analysis for program initiatives What We're Looking For Advanced degree or significant related experience 10+ years of pharmacy-related experience Extensive experience in Medicaid program integrity, FWA operations, pharmacy network management, or related healthcare regulatory fields Experience interacting with clients in the healthcare industry Track record of cross-functional leadership of teams and projects spanning people, process, and technology Excellent communication skills, with the ability to communicate externally and with senior executives Innovative forward thinker with excellent leadership skills Proven success leading teams and developing leaders Strong understanding of Medicaid regulations, pharmacy operations, and provider network dynamics Ability to build relationships with regulators, providers, and internal stakeholders Strategic mindset with the ability to execute in a fast-paced, highly regulated environment What You Should Expect In This Role This position is 100% remote within the US Approximately 20% of travel to support key client meetings T