Hi, we're Oscar. Were hiring an Investigator to join our Special Investigations Unit (SIU).
Oscar is the first health insurance company built around a full stack technology platform & a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselvesone that behaves like a doctor in the family.
About the role:
The SIU runs or coordinates activities across Oscar to reduce the incidence & impact of fraud, waste, and/or abuse (FWA) on all our operations.
Within the SIU, your primary role will be to support Oscar in its fight against fraud. Joining this dynamic team will expose you to the latest trends & patterns in FWA across the healthcare industry & provide you with the chance to fight FWA using tools & big data. Your work will not only lead to savings & recoupments for Oscar as a company, but to more affordable & higher-quality health care for the members we serve.
Primary Duties & Responsibilities
- Identify & conduct investigations into known or suspected FWA, primarily in the broker space as well as pharmacy space through Pharmacy Benefit Manager oversight. Refine your process & practices to seek greater efficiency & better use of data & technology
- Develop documentation to substantiate findings, including formal reports, graphs, audit logs, & other supporting documentation.
- Meet targets through investigations & internal process improvements which should, at least initially, increase year-over-year for FWA recoupments & savings
- Perform root cause analysis so as to inform future algorithmic identification of similar claims or cases & associated savings (i.e., help move identified case types from pay-and-chase to preventive edits & pre-payment activity)
- Make referrals to, maintain relationships with, & respond to requests from regulatory & law enforcement officials
- Participate in the development & presentation of FWA-related education for Oscar teams.
You will report into the Lead Investigator. This is a remote role, you are able to work remotely in one of the following states: Arizona, California, Connecticut, Florida, Georgia, Illinois, Maryland, Massachusetts, Michigan, New Jersey, New Mexico, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Virginia, or Washington.
Note, this list of states is subject to change.
Required education & experience
- This role requires a bachelors degree in Criminal Justice or a related field, OR at least five (5) years of insurance claims investigation experience or professional investigation experience with law enforcement agencies
- Knowledge of applicable fraud statutes & regulations, & of federal guidelines on recoupments & other anti-FWA activity
- Experience handling confidential information & following policies, rules, & regulations
Preferred education & experience
- Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML [Anti-Money Laundering] & Fraud Professional (CAFP), or similar
- Certified Professional Coder (CPC) or similar
- Knowledge of applicable state & federal fraud statutes & regulations, & of guidelines on recoupments & other anti-FWA activity
- Experience working in health insurance specifically with claims processing, billing, reimbursement, or provider contracting.
- Experience with HIPAA, data privacy, and/or data security processes
- Experience working with regulators governing (public or private) health insurance carriers
Life at Oscar:
At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves & find both belonging & support. We're on a mission to change health care -- an experience made whole by our unique backgrounds & perspectives.
We encourage our members to care for their whole selves, & we encourage our employees to do the same with comprehensive medical benefits, generous paid-time off, paid parental leave, retirement plans, company social events, stocked kitchens, wellness programs, & volunteer opportunities.
Oscar applicants are considered solely based on their qualifications, without regard to applicants disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (firstname.lastname@example.org) to make the need for an accommodation known.
Pay Transparency Policy:
Oscar ensures that you won't be discharged or discriminated against based on whether you've inquired about, discussed, or disclosed your pay. Read the full policy here.
COVID-19 vaccine requirements for in-person work:
To protect the health & safety of our employees, we require any employee conducting in-person work* to be fully vaccinated against COVID-19 by their start date.
If you are unable to be vaccinated due to medical or protected religious reasons, please reach out to our Benefits team at email@example.com to submit an accommodations request.
*Note: In-person work includes: employees required to work from our offices (either full-time or part-time), employees conducting sales work in the field & employees conducting at-home or in-person visits with members.