SIU Investigator, Senior Analyst

5 days ago


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

The SIU Investigator, Senior Analyst will be responsible for investigating changes in aberrant behavior observed in claims and enrollment data. This individual will work independently to analyze data, manage investigative caseload, and resolve cases through overpayment recovery, measuring behavior change, and completing necessary reporting to meet monetary and case load targets.

Key Responsibilities
  • Investigate claims and enrollment data to identify aberrant behavior
  • 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
Requirements
  • 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
Preferred Qualifications
  • Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML 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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