Lead Data Scientist- Fraud, Waste & Abuse

Cohere Health-posted 3 months ago
$148,000 - $168,000/Yr
Full-time • Senior
501-1,000 employees
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We are looking for innovative and creative individuals who seize opportunities to uncover hidden drivers, impacts, and key influences to support our product, leadership and clinical teams by applying optimization and statistical methods on a variety of data. You will work closely with the clinical program and product teams to support decision-making and will dig into a wide range of strategic and clinical problems. As a growing organization, we have built a team of talented and experienced people who are passionate about helping providers and patients and this is a position that offers the ability to make a substantial impact on the company with rapid growth opportunities. You will be part of a growing data science team within the technology organization.

  • Drive strategic data science initiatives that focus on healthcare fraud, waste and abuse including identification, investigation, validation, escalation and prevention.
  • Perform proactive fraud, waste and abuse detection analysis derived from various monitoring based data sources.
  • Serve as a subject matter expert on identifying and discovering claim and authorization outliers and interpret and analyze data to accurately assess and demonstrate key insights into trends and opportunities.
  • Independently lead in-depth analyses of a variety of healthcare and product data sources to investigate suspicious activities, and prepare detailed reports of their findings.
  • Stay up-to-date with the latest industry trends, regulatory changes, and emerging fraud schemes to enhance detection strategies.
  • Maintain meticulous methodology documentation and present findings or recommendations to leadership group.
  • Strong communication skills with the unique ability to translate business needs from stakeholders into data science technical requirements and translate data science results back to business and clinical units.
  • Present information using data visualization techniques and propose solutions and strategies to business challenges.
  • MSc or higher degree in a data science/ analytics, statistics, mathematics, engineering related field.
  • 7+ years hands-on data science experience at a company where health outcome performance were critical to the mission, preferably a healthcare insurance company.
  • Expert in conducting data mining in the healthcare insurance industry and claims-related experience and knowledge of coding, reimbursement, and claims processing policies.
  • Knowledge of the law and regulations as it relates to FWA investigations and familiar with CMS medicare and medicaid policies.
  • Proficient in current modeling approaches, standard scientific methods for intervention based analysis, trend identification, causal inference, and pattern detection.
  • Strong experience using a variety of data mining/data analysis methods, utilizing a variety of analytic tools, building and implementing models, creating algorithms and running simulations.
  • Experience with programming languages (Python, PySpark, Scala and/or Spark SQL).
  • Experience with graph database managing clinical concept is a big plus.
  • Fully remote opportunity with about x% travel.
  • Medical, dental, vision, life, disability insurance, and Employee Assistance Program.
  • 401K retirement plan with company match; flexible spending and health savings account.
  • Up to 184 hours (23 days) of PTO per year + company holidays.
  • Up to 14 weeks of paid parental leave.
  • Pet insurance.
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