Senior SIU Investigator — Fraud & Compliance (Remote)

Oscar-Health-; Miami (FL); Remote; USD 72,000 - 95,000; Full time

Benefits offered by this job

Unlimited vacation

Annual performance bonuses

Medical, dental, and vision benefits

Job summary

Oscar Health in the United States is seeking a Senior Analyst, Special Investigations Unit Investigator to detect and investigate aberrant behavior in claims and enrollment data and drive savings through preventive edits and recoupments.

The role reports to the Investigations Manager, SIU, and offers a remote work arrangement with eligibility for benefits, unlimited vacation, and annual performance bonuses.

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
• Bachelor's degree in Criminal Justice or a related field
• Experience working in health insurance across several product lines specifically with claims processing, billing, reimbursement, or provider contracting.
• Experience with HIPAA, data privacy, and/or data security processes
• Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML and Fraud Professional (CAFP), or similar
• Certified Professional Coder (CPC) or similar

Responsibilities

• Identify and conduct investigations into 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- which should, at least initially, increase year-over-year - for FWA recoupments and savings
• Perform analysis on prior cases to inform future identification of similar claims or cases and associated savings (i.e., help move from pay-and-chase to preventive edits and prepayment activity)
• 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

FWA investigations

Regulatory compliance

Data analysis

Education

Bachelor's degree in Criminal Justice or related field

Certified Fraud Examiner (CFE)

Accredited Healthcare Fraud Investigator (AHFI)

Certified AML and Fraud Professional (CAFP)

Certified Professional Coder (CPC)

Job description

Oscar Health in the United States is seeking a Senior Analyst, Special Investigations Unit Investigator to detect and investigate aberrant behavior in claims and enrollment data and drive savings through preventive edits and recoupments.

The role reports to the Investigations Manager, SIU, and offers a remote work arrangement with eligibility for benefits, unlimited vacation, and annual performance bonuses.