Senior Analyst, SIU Investigator
Core
Detect, investigate, and produce change in aberrant behavior observed in claims and enrollment data to recover overpayments and prevent fraud waste and abuse (FWA).
Role type
Senior IC fraud investigator (health insurance)
Builds
FWA recoupments and savings through investigations and internal process improvements
Domain
Health insurance / Fraud detection
Required skills
Insurance claims investigation, Fraud statutes and regulations, Federal guidelines on recoupments, Data analysis, Report writing, Process improvement
Preferred skills
Health insurance product lines experience, HIPAA and data privacy, Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC)
Technologies
Audit logs, Graphs
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 for FWA recoupments and savings; Perform analysis on prior cases to inform future identification of similar claims or cases and associated savings; Participate in the development and presentation of FWA-related education for Oscar teams
Seniority
Senior, hands-on IC
