Program Integrity Data Scientist III

CareSource; Dayton (OH); Hybrid; USD 94,000 - 165,000; Full time

Job summary

CareSource is seeking a Program Integrity Data Scientist III to lead the design, development, and deployment of advanced analytical solutions for payment accuracy, anomaly detection, and FWA prevention. You will mentor junior analysts and guide enterprise program integrity strategies while delivering dashboards and insights for executive decision-making.

The role emphasizes leadership in complex investigations, predictive modeling, and cross-functional collaboration with legal and operations

Qualifications

• Bachelor's degree or equivalent in a related field.
• 5+ years data analysis/analytic programming.
• 1+ year cloud services experience (Azure/AWS/GCP) and modern data stack preferred.
• Healthcare experience required.
• Experience with deep learning, graph analytics, or GNNs preferred.

Responsibilities

• Design, develop, and deploy advanced analytical solutions for payment integrity and FWA.
• Lead predictive modeling and anomaly detection initiatives.
• Mentor analysts and data scientists through reviews and coaching.
• Develop dashboards and reporting to demonstrate model performance and outcomes.
• Collaborate with legal to support proceedings with data and analyses.
• Present findings to leadership and stakeholders.

Skills

SQL

Python

R

Statistical analysis

Machine learning

Education

Bachelor's degree in Data Science, Mathematics, Statistics, Engineering, CS

Tools

Power BI

Databricks

Snowflake

Azure/AWS/GCP

SAS

Job description

Job Summary

The Program Integrity Data Scientist III is responsible for leading the design, development, and deployment of advanced analytical solutions that support payment accuracy, anomaly detection, and Fraud, Waste, and Abuse (FWA) prevention and recovery efforts. This role serves as a senior analytical resource, providing technical leadership across complex investigations, predictive modeling initiatives, and enterprise program integrity strategies while mentoring junior analysts and data scientists.

Essential Functions

• Lead the design, development, and implementation of advanced algorithms that identify claims for pre- and post-payment intervention related to potential Fraud, Waste, and Abuse.
• Analyze and quantify claim payment issues and provide recommendations to mitigate identified program integrity risks.
• Identify emerging trends, risks, and patterns across multiple healthcare datasets and recommend strategic interventions to improve program integrity outcomes.
• Mentor and provide technical guidance to analysts and data scientists through code reviews, analytical reviews, and best practice recommendations.
• Evaluate emerging analytical, machine learning, and AI techniques to improve fraud detection, anomaly identification, and payment integrity efforts.
• Conduct outcome analyses to determine impact and effectiveness of corporate program and payment integrity initiatives.
• Lead the examination and interpretation of complex data relationships to support payment integrity, anomaly detection, and FWA investigations.
• Lead monitoring and investigation of anomalies and emerging trends associated with potential Fraud, Waste, and Abuse activities across the enterprise.
• Collaborate with the legal department, generating data and analyses to support legal proceedings.
• Develop hypothesis tests and extrapolations on statistically valid samples to establish outlier behavior patterns and potential recoupment.
• Lead development and communication of analytical strategies, project plans, methodologies, and investigative approaches for complex initiatives.
• Design and develop advanced dashboards, visualizations, and reporting solutions that demonstrate model performance, program effectiveness, and program integrity outcomes.
• Lead development of AI-enabled and business intelligence dashboards that support investigator workflows, fraud detection activities, operational monitoring, and executive decision-making.
• Provide statistical validation and analysis of outcomes associated with clinical programs and interventions.
• Provide technical leadership in integrating analytical solutions with enterprise systems, platforms, and operational workflows.
• Present analytical findings, strategic recommendations, and program integrity insights to leadership and key stakeholders.
• Lead preparation and deployment of production-ready analytical code, models, and automated decision-support solutions.
• Research policy, billing guidelines, CMS direction and others to ideate new fraud, waste and abuse concepts to implement.
• Perform any other job related duties as requested.

Education and Experience

• Bachelor's degree in Data Science, Mathematics, Statistics, Engineering, Computer Science, or a related field required
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Five (5) years data analysis and/or analytic programming required
• One (1) year Experience with cloud services (such as Azure, AWS or GCP) and modern data stack (such as Databricks or Snowflake) preferred
• Healthcare experience required
• Experience supporting payment integrity, fraud detection, audit recovery, SIU, or program integrity initiatives preferred
• Experience developing and applying deep learning, neural network, graph analytics, or graph neural network (GNN) solutions for fraud detection, anomaly identification, payment integrity, or healthcare analytics initiatives preferred

Competencies, Knowledge and Skills

• Advanced proficiency in SQL and at least one programming language such as Python or R
• Familiarity with SAS is preferred
• Proficient in designing and developing dashboards and reporting solutions using Power BI or similar business intelligence platforms
• Ability to perform advanced statistical analyses and techniques including t-tests, ANOVAs, z-tests, statistical extrapolations, non-parametric significance testing, and sampling methodologies
• Advanced knowledge of predictive modeling, machine learning, deep learning, neural networks, graph analytics, graph neural networks (GNNs), clustering, dimensionality reduction, anomaly detection, and natural language processing
• Proficient in feature engineering techniques and exploratory data analysis
• Ability to apply advanced analytical, artificial intelligence, and graph-based techniques to identify complex provider, member, claim, and organizational relationships associated with payment integrity, Fraud, Waste, and Abuse (FWA), anomaly detection, and recovery opportunities
• Ability to analyze large quantities of information and identify patterns, irregularities, and deficiencies
• Strong knowledge of healthcare coding, billing processes, reimbursement methodologies, claims adjudication and Program Integrity concepts
• Proficient with MS office (Excel, PowerPoint, Word, Access)
• Demonstrated critical thinking, verbal communication, presentation and written communication skills
• Ability to independently lead analytical initiatives and collaborate effectively across cross-functional teams
• Familiarity with developing AI-enabled analytical solutions supporting fraud detection, anomaly identification, and payment integrity operations
• Ability to mentor analysts and data scientists through analytical reviews, statistical guidance, and technical coaching

Licensure and Certification

None

Working Conditions

General office environment; may be required to sit or stand for extended periods of time

Up to 15% (occasional) travel to attend meetings, trainings, and conferences may be required

Compensation Range

$94,100.00 - $164,800.00

CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance.

We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Organization Level Competencies

Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business

Job Description Exclusion

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time.

Equal Opportunity Employer

CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

CareSource Mission

The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference-makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer-centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we're looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.