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Salary: USD 67,813 - 98,894 / annual
Oscar Health is seeking a Senior Analyst, Special Investigations Unit Clinical Investigator to detect and audit aberrant billing patterns within claims and clinical documentation. In this role, you will leverage forensic clinical expertise to protect the integrity of healthcare spend by performing comprehensive pre-payment and post-payment reviews of medical records. You will ensure billed services align with established clinical guidelines, CMS regulations, and contractual obligations.
Key responsibilities include identifying and conducting clinical audits into suspected fraud, waste, and abuse (FWA) with high autonomy. You will analyze provider behavior to identify sophisticated schemes such as record cloning, upcoding, and unbundling that may evade automated systems. As a clinical subject matter expert, you will translate audit findings into actionable education and facilitate professional discussions with colleagues and providers to correct billing behaviors and promote long-term compliance.
You will document findings through formal reports, graphs, audit logs, and supporting documentation. You will partner with clinical and non-clinical investigators to build evidentiary files for potential recovery, legal action, or referrals to appropriate outside agencies. You will also participate in developing and presenting FWA-related education for Oscar teams and contribute to metrics aligned with unit goals.
This remote position is open to candidates residing in Arizona, Florida, Georgia, Illinois, Iowa, Kansas, Michigan, Missouri, Nebraska, New Jersey, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, and Virginia. Candidates within commutable distance to the New York City office (Hudson Square) or Tempe office (off the 101 at University Ave) will be expected to work in-office at least three days per week, with Thursdays as a required in-office day.
