About the job
Join Oscar as a Senior Analyst in our Special Investigations Unit (SIU) and play a crucial role in safeguarding the integrity of healthcare spending. At Oscar, we are committed to redefining health insurance through a robust technology platform and a member-centric approach. Since our inception in 2012, we have aimed to create a health insurance experience that feels personal and supportive, much like having a doctor in the family.
About the Role:
As a Senior Analyst, SIU Clinical Investigator, you will utilize your forensic clinical expertise to detect and audit irregular billing patterns in claims and clinical documents. Your responsibilities will include conducting thorough pre-payment and post-payment reviews of medical records to ensure that billed services comply with clinical guidelines, CMS regulations, and contractual obligations. You will analyze provider behaviors to uncover potential fraud schemes such as record cloning, upcoding, and unbundling that may elude automated detection systems. As a clinical subject matter expert, you will translate audit findings into actionable education, engaging in professional discussions with colleagues and providers to correct billing practices and foster long-term compliance. Collaborating with both clinical and non-clinical investigators, you will help build evidentiary files for potential recovery, legal actions, or referrals to appropriate agencies.
You will report to the Investigations Manager, SIU.

