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Salary: USD 72,036 - 94,547 / annual
Oscar Health is seeking a Senior Analyst, Special Investigations Unit Investigator to detect, investigate, and resolve fraud, waste, and abuse (FWA) in claims and enrollment data. You will work with high autonomy to identify and conduct investigations into known or suspected FWA, develop substantiating documentation including formal reports, graphs, and audit logs, and meet targets for FWA recoupments and savings through investigations and internal process improvements.
Key responsibilities include:
- Identify and conduct investigations into known or suspected FWA with high autonomy
- Develop comprehensive documentation to substantiate findings, including formal reports, graphs, audit logs, and supporting materials
- Meet targets for FWA recoupments and savings through investigations and process improvements, with the goal of increasing year-over-year results
- Perform analysis on prior cases to inform future identification of similar claims and associated savings, moving from reactive "pay-and-chase" approaches to preventive edits and prepayment activity
- Participate in developing and presenting FWA-related education for Oscar teams
- Ensure compliance with all applicable laws and regulations
- Manage investigative caseload from identification through resolution, including overpayment recovery and necessary reporting
You will report to the Investigations Manager, SIU. This is a remote position open to candidates residing in Arizona, Florida, Georgia, or Texas. Occasional travel may be required for team meetings and company events.
Requirements:
- 3+ years of insurance claims investigation experience OR professional investigation experience with law enforcement agencies
- 1+ year of experience with applicable fraud statutes and regulations, and federal guidelines on recoupments and anti-FWA activity
Bonus qualifications:
- Bachelor's degree in Criminal Justice or related field
- Experience in health insurance across multiple product lines, 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 and Fraud Professional (CAFP), or similar certification
- Certified Professional Coder (CPC) or similar credential
