Lead Data Scientist- Fraud, Waste & Abuse
148000 - 175000 USD per year
Company:Cohere Health
Location:United States, EST, PST
Languages:English
Seniority level:Lead, 7+ years
Experience:7+ years
Skills:
LeadershipPythonArtificial IntelligenceData AnalysisData MiningMachine LearningData scienceScalaData visualization
Requirements:
- MSc or higher degree in a data science/ analytics, statistics, mathematics, engineering related field.
- 7+ years hands-on data science experience at a company where health outcome performance were critical to the mission, preferably a healthcare insurance company.
- Strong communication skills with the ability to translate business needs into data science requirements and data science results back to business and clinical units.
- Expert in conducting data mining in the healthcare insurance industry.
- Claims-related experience and knowledge of coding, reimbursement, and claims processing policies.
- Knowledge of laws and regulations related to FWA investigations and familiarity with CMS Medicare and Medicaid policies.
- Proficient in current modeling approaches, standard scientific methods for intervention-based analysis, trend identification, causal inference, and pattern detection.
- Strong experience using a variety of data mining/data analysis methods, utilizing a variety of analytic tools, building and implementing models, creating algorithms and running simulations.
- Experience with programming languages (Python, PySpark, Scala and/or Spark SQL).
- Experience with graph database managing clinical concept is a big plus.
- Experience with Amazon AWS cloud platform is a plus.
Responsibilities:
- Drive strategic data science initiatives focused on preventing and identifying healthcare fraud, waste, and abuse.
- Serve as a subject matter expert on identifying and discovering claim and authorization outliers.
- Interpret and analyze data to demonstrate key insights into trends and opportunities.
- Independently lead in-depth analyses of healthcare and product data sources to investigate suspicious activities.
- Prepare detailed reports of findings.
- Stay up-to-date with industry trends, regulatory changes, and emerging fraud schemes to enhance detection strategies.
- Maintain meticulous methodology documentation and present findings or recommendations to leadership.
- Present information using data visualization techniques.
- Propose solutions and strategies to business challenges.
