SIU Investigator

Oscar Health•Tempe, AZ

14d•$64,832 - $85,092•Remote

About The Position

The Senior Analyst, SIU Investigator identifies and investigates aberrant behavior observed in medical claims data and member enrollment data. You will manage an investigative caseload from case identification through to resolution, including data mining, investigation planning, data analysis, sampling, medical records requests, audit interpretation, overpayment recovery, reporting to regulatory agencies and monitoring ongoing provider behavior. The Senior Analyst will meet metrics set forth related to caseload, turn around times, and other unit-wide goals. You will report into the Investigations Manager, SIU.

Requirements

3+ years of healthcare fraud investigation experience or professional investigation experience with law enforcement agencies
3+ year experience with applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity

Nice To Haves

Bachelor's degree in Criminal Justice or a related field
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 suspected FWA with high autonomy
Document findings to include formal investigative reports, tables, graphs, audit logs, and other supporting documentation
Met metrics to align with caseload, turn around times, and other unit-wide goals
Continue to monitor providers with substantiated findings to track behavior change
Participate in the development and presentation of FWA-related education for Oscar teams
Build evidentiary files for potential recovery, legal action, and/or referrals to appropriate outside agencies
Compliance with all applicable laws and regulations
Other duties as assigned