SIU Investigator, Analyst

1 week ago

New York, New York, United States Oscar Health Full time
About the Role

Oscar Health is seeking a highly skilled SIU Investigator, Senior Analyst to join our team. As a key member of our SIU team, you will be responsible for investigating change in aberrant behavior observed in claims and enrollment data.

As a SIU Investigator, Senior Analyst, you will work independently to analyze data, manage investigative caseload from identification through to resolution, and complete necessary reporting to meet monetary and case load targets. You will also be responsible for performing root cause analysis to inform future algorithmic identification of similar claims or cases and associated savings.

This is an exciting opportunity to join a dynamic team and contribute to the success of Oscar Health. If you have a strong background in investigation and analysis, and are passionate about identifying and preventing fraudulent activity, we encourage you to apply.

Responsibilities
  • Investigate change in aberrant behavior observed in claims and enrollment data
  • Develop documentation to substantiate findings, including formal reports, graphs, audit logs, and other supporting documentation
  • Meet targets through investigations and internal process improvements for FWA recoupments and savings
  • Perform root cause analysis to inform future algorithmic identification of similar claims or cases and associated savings
  • Participate in the development and presentation of FWA-related education for Oscar teams
  • Perform coding reviews for flagged claims, to support Coding team
Qualifications
  • Bachelor's degree in Criminal Justice or a related field, OR at least 3 years of insurance claims investigation experience or professional investigation experience with law enforcement agencies
  • Knowledge of applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity
  • Experience handling confidential information and following policies, rules, and regulations
Bonus Points
  • 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
  • Experience working in health insurance across several products specifically with claims processing, billing, reimbursement, or provider contracting.
  • Experience with HIPAA, data privacy, and/or data security processes

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