SIU Investigator, Senior Analyst

Hi, we're Oscar. We're hiring a SIU Investigator, Sr. Analyst 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 SIU Investigator (Senior Analyst) primary purpose is to investigate change in aberrant behavior observed in claims and enrollment data. You will work independently to analyze data, and manage investigative caseload from identification through to resolution including overpayment recovery, measuring behavior change and completing necessary reporting to meet monetary and case load targets through investigations and internal process improvements– which should, at least initially, increase year-over-year – for FWA recoupments and savings.

You will report to the Senior Investigator, 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 Ave), 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, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, 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: $76,800 - 91,200 per year. The base pay for this role in all other locations is: $69,120 - $82,080 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 root cause analysis to inform future algorithmic identification of similar claims or cases and associated savings (i.e., help move identified case types from "pay-and-chase" to preventive edits and pre-payment activity)
• Participate in the development and presentation of FWA-related education for Oscar teams
• Perform coding reviews for flagged claims, to support Coding team

Qualifications

• Bachelor's degree in Criminal Justice or a related field, OR at least 3 years of insurance claims investigation experience or professional investigation experience with law enforcement agencies
• Knowledge of applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity
• Experience handling confidential information and following policies, rules, and regulations

Bonus Points

• 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
• 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

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Last updated on Feb 6, 2024