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CareSource · 1 day ago

REMOTE - Senior Manager, Program Integrity Data Science - R11184

United States

Full-time

Remote

Mid, Senior Level

$113K/yr - $198K/yr

6+ years exp

CareSource is a healthcare organization dedicated to improving lives. The Senior Manager, Program Integrity Data Science will oversee a team responsible for developing algorithms to identify claims for intervention, ensuring accuracy and mitigating fraud within the health plans.

Health CareMedicalNon Profit

Comp. & Benefits

H1B Sponsor Likely

Responsibilities

Oversee and manage an ever-changing portfolio of claim-centric algorithms that identify claims pre and post-pay that can be moved into various workflows for intervention – including a request for medical record and audit (correct coding and medical necessity), a downcode to revised reimbursement, etc

Hands-on management of data science function, including technical development and / or direct oversight of technical work product developed by the team

Responsible for providing depositions and testifying in court to support legal actions initiated by CareSource and the Attorney General

Assist in the deployment of advanced analytic solutions into the various functions within Program Integrity (Investigations, Regulatory, Audit, Prepay, etc.)

Conduct outcome analyses to determine impact and effectiveness of corporate and Special Investigations Unit (SIU) initiatives

Translate complex healthcare policies into practical strategies that help identify and enhance opportunities for Program Integrity

Develop hypothesis tests and extrapolations on statistically valid samples to establish outlier behavior patterns and potential recoupment

Assist in the execution and support of various analytic studies that establish Program Integrity as a leader in FWA analytics across markets

Collaborate with cross-functional teams to solve Program Integrity problems, develop new algorithms and models, and identify trends and opportunities

Manage all efforts of your analytics team focusing on thorough but timely investigations, highest impact prioritization, root cause identification, statistical evidence development and investigative actions

Use descriptive statistical techniques to measure impact of various actions/studies, internal and external, develop sampling and hypothesis testing to help the organization determine outcomes

Lead a team of data scientists and statisticians to develop and drive innovative approaches to increase PI effectiveness and efficiency

Develop and implement predictive models, algorithms, and statistical techniques to extract insights from large and complex healthcare datasets

Utilize machine learning algorithms to identify patterns, trends, and opportunities for improving operational efficiency, cost containment, and patient care

Monitor and provide explanation of anomalies related to trends associated with the potential for Fraud Waste and Abuse across the corporate enterprise

Stay abreast of emerging trends, tools, and techniques in predictive analytics, data science, and healthcare informatics to drive innovation and continuous improvement

Provide strategic guidance and recommendations to senior leadership based on data analysis and predictive modeling results

Mentor and develop team members, fostering a collaborative and innovative work environment

Ensure compliance with data privacy and security regulations and maintain the highest standards of data integrity

Perform any other job related duties as requested

Qualification

Statistical modelingMachine learningPredictive analyticsData science leadershipCloud ServicesHealthcare data analysisLegal auditing experienceFeature engineeringProject managementCommunication skillsProblem-solving skillsCritical thinkingMentoringCollaboration

Required

Bachelor's degree in Data Science, Mathematics, Statistics, Criminal Justice, Medical/Health Care Field, or another related field required

Six (6) years Data Science, Health Care, Legal, Auditing, Claims and/or Investigative Services required

One (1) year Cloud Services (such as Azure, AWS or GCP) and modern data stack (such as Databricks or Snowflakes) required

Two (2) years of leadership/supervisory experience required

Strong expertise in statistical modeling, machine learning techniques, and predictive analytics tools such as Python, or R

Proficiency with MS office (Excel, PowerPoint, Word, Access)

Ability to perform advanced statistical analyses and techniques including t-tests, ANOVAs, z-tests, statistical extrapolations, non-parametric significance testing, and sampling methodologies

Demonstrated experience interpreting and applying healthcare policy within clinical, operational, or investigative contexts

Expertise in legal, auditing, and investigative services, as well as proficiency in statistical modeling and anomaly detection

Extensive knowledge of predictive modeling, machine learning, and artificial intelligence

Familiarity with healthcare data sets, including claims data (Professional, facility, pharmacy), electronic health records (EHR), and population health data

Knowledge of healthcare operations, payer and provider models, and industry trends

Proficient in feature engineering techniques and exploratory data analysis

Excellent analytical, problem-solving, and critical-thinking skills, with the ability to translate complex data into actionable insights

Strong project management skills, with the ability to lead and prioritize multiple projects simultaneously

Excellent communication and presentation skills, with the ability to convey technical concepts to non-technical stakeholders

Leadership qualities, including the ability to mentor and develop a team, foster collaboration, and drive results

AAPC Certified Professional Coder required

Preferred

Master's degree in Data Science, Mathematics, Statistics, Criminal Justice, Medical/Health Care Field, or another related field preferred

Certified Fraud Examiner (CFE) preferred

Certifications through America's Health Insurance Plans (AHIP) preferred

Healthcare Anti-Fraud Association (HCAFA) and/or Managed Healthcare Professional (MHP) preferred

Accredited Health Care Fraud Investigator (AHFI) preferred

Benefits

You may qualify for a bonus tied to company and individual performance

Substantial and comprehensive total rewards package

Company

CareSource

Glassdoor3.8

CareSource provides managed care services to Medicaid beneficiaries.

Founded in 1989

Dayton, Ohio, USA

1001-5000 employees

https://www.caresource.com/

H1B Sponsorship

CareSource has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (30)

2024 (39)

2023 (35)

2022 (21)

2021 (37)

2020 (28)