Senior Analyst, SIU Investigator
Oscar Health•Florida, United States, FL
•$72,036 - $94,547•Remote
About The Position
The Senior Analyst, Special Investigations Unit Investigator detects, investigates, and produces change in aberrant behavior observed in claims and enrollment data. You will analyze data and manage investigative caseload from identification through to resolution including overpayment recovery, measuring behavior change and completing necessary reporting to meet monetary and caseload targets through investigations and internal process improvements for Fraud Waste and Abuse (FWA) recoupments and savings. You will report into the Investigations Manager, SIU.
Requirements
- 3+ years of insurance claims investigation experience or professional investigation experience with law enforcement agencies
- 1+ year experience with applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity
- Currently authorized to work in the United States on a full-time basis. Oscar will not sponsor applicants for this role.
Nice To Haves
- Bachelor's degree in Criminal Justice or a related field
- Experience working in health insurance across several product lines specifically with claims processing, billing, reimbursement, or provider contracting.
- Experience with HIPAA, data privacy, and/or data security processes
- Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML [Anti-Money Laundering] and Fraud Professional (CAFP), or similar
- Certified Professional Coder (CPC) or similar
Responsibilities
- Identify and conduct investigations into known or suspected FWA with high autonomy
- Develop documentation to substantiate findings, including formal reports, graphs, audit logs, and other supporting documentation.
- Meet targets through investigations and internal process improvements – which should, at least initially, increase year-over-year – for FWA recoupments and savings
- Perform analysis on prior cases to inform future identification of similar claims or cases and associated savings (i.e., help move from “pay-and-chase” to preventive edits and prepayment activity)
- Participate in the development and presentation of FWA-related education for Oscar teams
- Compliance with all applicable laws and regulations
- Other duties as assigned
Benefits
- medical
- dental
- vision benefits
- 11 paid holidays
- paid sick time
- paid parental leave
- 401(k) plan participation
- life and disability insurance
- paid wellness time and reimbursements
- unlimited vacation program
- annual performance bonuses
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
