Remote SIU Investigator - FWA Analytics & Recoupments

Oscar-Health-; Dallas (TX); Remote; USD 72,000 - 95,000; Full time

Benefits offered by this job

Unlimited vacation

Annual performance bonuses

Medical, dental, vision benefits

Job summary

Oscar Health is seeking a Senior Analyst, SIU Investigator to detect and investigate aberrant behavior in claims and enrollment data. You will manage caseloads from identification through resolution, including overpayment recovery, and contribute to savings through process improvements for fraud, waste and abuse (FWA).

The role reports to the Investigations Manager, SIU, and is remote to candidates in AZ, FL, GA, or TX.

Qualifications

• 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.
• Experience working in health insurance across several product lines with claims processing, billing, reimbursement, or provider contracting.
• Experience with HIPAA, data privacy, and/or data security processes.
• Certified Fraud Examiner (CFE), AHFI, CAFP, or similar.
• Certified Professional Coder (CPC) or similar.

Responsibilities

• Identify and investigate known or suspected FWA with high autonomy.
• 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 analysis on prior cases to inform future identification of similar claims or cases and associated savings.
• Participate in the development and presentation of FWA-related education for Oscar teams.
• Compliance with all applicable laws and regulations.
• Other duties as assigned.

Skills

Insurance claims investigation

FWA awareness

Education

Bachelor's degree in Criminal Justice or related field

Job description

Oscar Health is seeking a Senior Analyst, SIU Investigator to detect and investigate aberrant behavior in claims and enrollment data. You will manage caseloads from identification through resolution, including overpayment recovery, and contribute to savings through process improvements for fraud, waste and abuse (FWA).

The role reports to the Investigations Manager, SIU, and is remote to candidates in AZ, FL, GA, or TX.