Decision Scientist
Core
Transform complex healthcare data into actionable insights to drive affordability, strengthen fraud/waste/error detection, and improve operational performance within Payment Integrity and Special Investigations initiatives.
Role type
Senior Decision Scientist (Healthcare Analytics & Fraud Detection)
Builds
Fraud detection algorithms, business rules, and analytical solutions for payment integrity
Domain
Healthcare / Insurance / Fraud Detection
Deliverable
production ML models
Required skills
Clinical coding expertise, Healthcare auditing/analytics, Claims data analysis (ACAS, QNXT, HRP), Business rule development, Statistical analysis, Predictive methodologies, SAS, SQL, Python, R
Preferred skills
CPC certification, AHFI certification, Predictive analytics, Machine learning, Anomaly detection, Power BI, Tableau
Technologies
SAS, SQL, Python, R, ACAS, QNXT, HRP, Power BI, Tableau
Responsibilities
Facilitate intake and prioritization of fraud and payment integrity opportunities; Apply clinical knowledge to interpret billing patterns and evaluate medical necessity; Develop and validate business rules and algorithms to detect FWE risks; Translate operational challenges into analytical solutions; Quantify financial impact and ROI of proposed actions; Collaborate with cross-functional stakeholders to design solutions aligning with enterprise goals.
Seniority
Senior, hands-on IC
