Program Integrity Data Scientist III

🔥 12 hours ago

🇺🇸 United States – Remote

💵 $94.1k - $164.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

📊 Data Scientist

🦅 H1B Visa Sponsor

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Lead the design, development, and implementation of advanced algorithms identifying claims for pre- and post-payment intervention related to potential Fraud, Waste, and Abuse • Analyze and quantify claim payment issues and recommend mitigations for program integrity risks • Identify trends, risks, and patterns across healthcare datasets and recommend strategic interventions • Mentor analysts and data scientists through code reviews, analytical reviews, and best-practice recommendations • Evaluate analytical, machine learning, and AI techniques for fraud detection, anomaly identification, and payment integrity • Conduct outcome analyses for corporate program and payment integrity initiatives • Lead complex data relationship analysis for payment integrity, anomaly detection, and FWA investigations • Monitor and investigate anomalies and emerging FWA trends across the enterprise • Collaborate with legal to generate data and analyses supporting legal proceedings • Develop hypothesis tests and extrapolations on statistically valid samples to establish outlier behavior and potential recoupment • Lead analytical strategies, project plans, methodologies, and investigative approaches • Design dashboards, visualizations, and reporting solutions demonstrating model performance and program outcomes • Develop AI-enabled and business intelligence dashboards supporting investigator workflows, fraud detection, operational monitoring, and executive decision-making • Provide statistical validation and analysis of clinical program and intervention outcomes • Integrate analytical solutions with enterprise systems, platforms, and operational workflows • Present analytical findings and strategic recommendations to leadership and stakeholders • Lead preparation and deployment of production-ready code, models, and automated decision-support solutions • Research policy, billing guidelines, and CMS direction to develop new fraud, waste, and abuse concepts

🎯 Requirements

• Bachelor's degree in Data Science, Mathematics, Statistics, Engineering, Computer Science, or a related field required • Equivalent years of relevant work experience may be accepted in lieu of required education • Five (5) years of data analysis and/or analytic programming required • Healthcare experience required • One (1) year of experience with cloud services such as Azure, AWS, or GCP and modern data stacks such as Databricks or Snowflake preferred • Experience supporting payment integrity, fraud detection, audit recovery, SIU, or program integrity initiatives preferred • Experience developing and applying deep learning, neural network, graph analytics, or graph neural network solutions preferred • Advanced proficiency in SQL and at least one programming language such as Python or R • Familiarity with SAS preferred • Proficiency designing and developing dashboards and reporting solutions using Power BI or similar platforms • Advanced statistical analysis skills, including t-tests, ANOVAs, z-tests, statistical extrapolations, non-parametric significance testing, and sampling methodologies • Advanced knowledge of predictive modeling, machine learning, deep learning, neural networks, graph analytics, graph neural networks, clustering, dimensionality reduction, anomaly detection, and natural language processing • Proficiency in feature engineering and exploratory data analysis • Knowledge of healthcare coding, billing processes, reimbursement methodologies, claims adjudication, and program integrity concepts • Proficiency with Microsoft Office, including Excel, PowerPoint, Word, and Access • Critical thinking, verbal communication, presentation, and written communication skills • Ability to independently lead analytical initiatives and collaborate across cross-functional teams • Ability to mentor analysts and data scientists • No licensure or certification required

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Employee well-being support • Equal opportunity and belonging-focused workplace • Up to 15% occasional travel to meetings, trainings, and conferences