SIU Investigator

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Quick Summary

Key Responsibilities

Identify and conduct investigations into suspected FWA with high autonomy Document findings to include formal investigative reports, tables, graphs, audit logs,

Requirements Summary

3+ years of healthcare fraud investigation experience or professional investigation experience with law enforcement agencies 3+ year experience with applicable fraud statutes and regulations,

Technical Tools

OtherInvestigator

Hi, we're Oscar. We're hiring a SIU Investigator to join our SIU team.

Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family.

About the Role

~1 min read

The SIU Investigator identifies and investigates aberrant behavior observed in medical claims data and member enrollment data. You will manage an investigative caseload from case identification through to resolution, including data mining, investigation planning, data analysis, sampling, medical records requests, audit interpretation, overpayment recovery, reporting to regulatory agencies and monitoring ongoing provider behavior. The Senior Analyst will meet metrics set forth related to caseload, turn around times, and other unit-wide goals.

You will report into the Investigations Manager, SIU.

Responsibilities

~1 min read

→Identify and conduct investigations into suspected FWA with high autonomy
→Document findings to include formal investigative reports, tables, graphs, audit logs, and other supporting documentation
→Met metrics to align with caseload, turn around times, and other unit-wide goals
→Continue to monitor providers with substantiated findings to track behavior change
→Participate in the development and presentation of FWA-related education for Oscar teams
→Build evidentiary files for potential recovery, legal action, and/or referrals to appropriate outside agencies
→Compliance with all applicable laws and regulations
→Other duties as assigned

Requirements

~1 min read

3+ years of healthcare fraud investigation experience or professional investigation experience with law enforcement agencies
3+ year experience with applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity

Nice to Have

~2 min read

Bachelor's degree in Criminal Justice or a related field
Experience with HIPAA, data privacy, and/or data security processes
Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML [Anti-Money Laundering] and Fraud Professional (CAFP), or similar
Certified Professional Coder (CPC) or similar

This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here.

At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives.

Pay Transparency: Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements.

Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts.

Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications, without regard to applicant’s disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known.

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