Program Integrity Data Scientist III
Core
Lead design, development, and deployment of advanced analytical solutions for payment accuracy, anomaly detection, and Fraud, Waste, and Abuse (FWA) prevention in healthcare.
Role type
Senior IC Program Integrity Data Scientist
Builds
Production-ready analytical code, models, automated decision-support solutions, and AI-enabled dashboards for fraud detection and payment integrity.
Domain
Healthcare / Program Integrity / Fraud Detection
Deliverable
production ML models | dashboards & analysis
Required skills
Advanced SQL, Python or R, predictive modeling, machine learning, deep learning, neural networks, graph analytics, graph neural networks (GNNs), clustering, dimensionality reduction, anomaly detection, natural language processing, feature engineering, exploratory data analysis, advanced statistical analyses (t-tests, ANOVAs, z-tests, non-parametric testing), healthcare coding knowledge, claims adjudication concepts
Preferred skills
Cloud services (Azure, AWS, GCP), modern data stack (Databricks, Snowflake), deep learning for fraud detection, graph analytics for healthcare analytics, SAS, Power BI
Technologies
Azure, AWS, GCP, Databricks, Snowflake, Power BI, Python, R, SQL, SAS
Responsibilities
Lead design and implementation of algorithms to identify claims for pre- and post-payment intervention; Analyze and quantify claim payment issues to mitigate risks; Identify emerging trends and patterns across healthcare datasets; Mentor junior analysts and data scientists; Evaluate emerging AI and ML techniques for fraud detection; Conduct outcome analyses for program effectiveness; Lead examination of complex data relationships for FWA investigations; Collaborate with legal department for data generation; Develop hypothesis tests to establish outlier behavior patterns; Lead development of analytical strategies and project plans; Design and develop advanced dashboards for model performance and integrity outcomes; Present findings and recommendations to leadership; Lead preparation and deployment of production-ready code and models; Research policy and billing guidelines to ideate new FWA concepts
Seniority
Senior, hands-on IC with mentorship responsibilities
