SIU Investigator

Summary

Join Oscar, a health insurance company focused on technology and member service, as a Senior Analyst, Special Investigations Unit Investigator. You will investigate claims and enrollment data for aberrant behavior, analyze data, manage investigative caseload, and recover overpayments. You will also develop documentation, meet targets, perform analysis, participate in FWA-related education, and ensure compliance with applicable laws and regulations. This role is remote or work-from-home, with the option to work in the New York City, Tempe, or Los Angeles office at least two days a week. You must reside in one of the specified states, and the base pay varies by location.

Requirements

• 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

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

Preferred Qualifications

• 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

Benefits

• Medical, dental, and vision benefits
• 11 paid holidays
• Paid sick time
• Paid parental leave
• 401(k) plan participation
• Life and disability insurance
• Paid wellness time and reimbursements