SIU Investigator (Healthcare)

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

Oscar is the first health insurance company built around a full stack technology platform and a 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

The Senior Analyst, Special Investigations Unit Investigator detects, investigates, and produces change in aberrant behavior observed in claims and enrollment data.  You will analyze data, and manages investigative caseload from identification through to resolution including overpayment recovery, measuring behavior change and completing necessary reporting to meet monetary and caseload targets through investigations and internal process improvements for Fraud Waste and Abuse (FWA) recoupments and savings.

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You will report to the Associate Director, SIU.

Work Location: 

Oscar is a blended work culture where everyone, regardless of work type or location, feels connected to their teammates, our culture and our mission. 

If you live within commutable distance to our New York City office (in Hudson Square), our Tempe office (off the 101 at University Dr), or our Los Angeles office (in Marina Del Rey), you will be expected to come into the office at least two days each week. Otherwise, this is a remote / work-from-home role.  

You must reside in one of the following states: Alabama, Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change. #LI-Remote

Pay Transparency:

The base pay for this role in the states of California, Connecticut, New Jersey, New York, and Washington is: $69,600 - $91,350 per year. The base pay for this role in all other locations is: $62,640 - $82,215 per year. You are also eligible for employee benefits, participation in Oscar’s unlimited vacation program and annual performance bonuses.

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

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

Bonus Points

• Bachelor’s degree in Criminal Justice or a related field
• Experience working in health insurance across several products 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 [Anti-Money Laundering] and Fraud Professional (CAFP), or similar
• Certified Professional Coder (CPC) or similar