Senior Analyst, SIU Investigator

About the role:

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.

This is a remote position, open to candidates who reside in: Arizona, Florida, Georgia, Illinois, Iowa, Kansas, Michigan, Missouri, Nebraska, New Jersey, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas and Virginia. You will be fully remote; however, our approach to work may adapt over time. Future models could potentially involve a hybrid presence at the hub office associated with your metro area.

If you live within commutable distance to our New York City office (in Hudson Square) or our Tempe office (off the 101 at University Ave), you will be expected to come into the office at least three days each week. Otherwise, this is a remote / work-from-home role. Thursdays are a required in-office day for team meetings and events, while your other two office days are flexible to suit your schedule.

The base pay for this role in the states of New Jersey and New York is: $72,036 - $94,546 per year. The base pay for this role in all other locations is: $64,832 - $85,092 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program and annual performance bonuses.

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

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

Bonus points:

• 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