Job Description

Hi, we're Oscar. We're hiring an Investigator to join our Special Investigations Unit (SIU). 

Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family.

ABOUT THE ROLE:

The SIU runs or coordinates activities across Oscar to reduce the incidence and 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 and patterns in FWA across the healthcare industry – and provide you with the chance to fight FWA using tools and big data. Your work will not only lead to savings and recoupments for Oscar as a company, but to more affordable and higher-quality health care for the members we serve.

You will report into the Lead Investigator for SIU. This is a remote / work-from-home role. You must reside 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.

RESPONSIBILITIES 

• Identify and 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 and practices to seek greater efficiency and better use of data and technology

• Develop documentation to substantiate findings, including formal reports, graphs, audit logs, and other supporting documentation.

• Meet targets through investigations and internal process improvements– which should, at least initially, increase year-over-year – for FWA recoupments and savings

• Perform root cause analysis so as to inform future algorithmic identification of similar claims or cases and associated savings (i.e., help move identified case types from "pay-and-chase" to preventive edits and pre-payment activity)

• Make referrals to, maintain relationships with, and respond to requests from regulatory and law enforcement officials

• Participate in the development and presentation of FWA-related education for Oscar teams.

_ _REQUIREMENTS:

• a bachelor's 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 and regulations, and of federal guidelines on recoupments and other anti-FWA activity

• Experience handling confidential information and following policies, rules, and regulations

BONUS POINTS:

• Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML [Anti-Money Laundering] and Fraud Professional (CAFP), or similar

• Certified Professional Coder (CPC) or similar

• Knowledge of applicable state and federal fraud statutes and regulations, and of guidelines on recoupments and 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 and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives.

We aim to make health care affordable and accessible for all, and apply this same vision to our perks and benefits, including: medical benefits, generous paid-time off, paid parental leave, retirement plans, company social events, stocked kitchens, wellness programs, and volunteer opportunities.

REASONABLE ACCOMMODATION:

Oscar applicants are considered solely based on their qualifications, without regard to applicant's disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) 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 and 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 accommodations@hioscar.com to submit an accommodations request.

*Note: In-person work includes: employees required to work from our offices, employees conducting sales work in the field and employees conducting at-home or in-person visits with members.