Senior Analyst, SIU Investigator
New
O
OscarHealth insurance
This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; or Texas.Full-TimeSenior
SalaryThe base pay for this role is: $72,036 - $94,547 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program and annual performance bonuses.
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Job Details
- Experience
- 3+ years of insurance claims investigation experience or professional investigation experience with law enforcement agencies; 1+ year experience with applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity
- Required Skills
- HIPAA
Requirements
- Have 3+ years of insurance claims investigation experience or professional investigation experience with law enforcement agencies.
- Have 1+ year of experience with applicable fraud statutes and regulations and federal guidelines on recoupments and other anti-FWA activity.
- Preferred: Bachelor's degree in Criminal Justice or a related field.
- Preferred: Health insurance experience across several product lines, including claims processing, billing, reimbursement, or provider contracting.
- Preferred: Experience with HIPAA, data privacy, and/or data security processes.
- Preferred: Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML and Fraud Professional (CAFP), or similar certification.
- Preferred: Certified Professional Coder (CPC) or similar certification.
Responsibilities
- Identify and investigate known or suspected FWA with high autonomy.
- Develop documentation to substantiate findings, including formal reports, graphs, audit logs, and supporting documentation.
- Meet targets for FWA recoupments and savings through investigations and internal process improvements.
- Analyze prior cases to inform identification of similar claims or cases and associated savings.
- Help move activity from “pay-and-chase” to preventive edits and prepayment activity.
- Participate in developing and presenting FWA-related education for Oscar teams.
- Comply with applicable laws and regulations.
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