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CareSource · 1 day ago

REMOTE - Program Integrity Data Scientist II - R11182

United States

Full-time

Remote

Mid Level

$83K/yr - $133K/yr

3+ years exp

CareSource is seeking a Program Integrity Data Scientist II who will be responsible for developing and managing analyses related to payment accuracy and fraud detection. The role involves building algorithms, analyzing claims, and collaborating with various departments to ensure the integrity of payment processes.

Health CareMedicalNon Profit

Comp. & Benefits

H1B Sponsor Likely

Responsibilities

Build concepts as algorithms that identify claims for pre- or post-pay intervention based on probability of fraud, waste, and abuse. Algorithms are implemented into production workflows for action: medical record request and audit, downcode adjustment, denial and remittance communication, etc

Analyze and quantify claim payment issues and provide recommendations to mitigate identified program integrity risks

Identify trends and patterns using standard corporate, processes, tools, reports and databases as well as leveraging other processes and data sources

Conduct outcome analyses to determine impact and effectiveness of corporate program and payment integrity initiatives

Collaborate on the examination and explanation of complex data relationships to answer questions identified either within the department or by other departments as it relates to payment accuracy, anomaly detection, and FWA

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

Collaborate with the Legal Department, generating data and analyses to support Legal proceedings

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

Create, maintain, and communicate an analytical plan for each project

Mine and analyze large structured and unstructured datasets

Employ wide range of data sources to develop algorithms for predicting risk and understanding drivers, detecting outliers, etc

Develop visualizations that demonstrate the efficacy of developed algorithms

Provide statistical validation and analysis of outcomes associated with clinical programs and interventions

Collaborate with other teams to integrate with existing solutions

Communicate results and ideas to key stakeholders

Prepare code for operationalization of end-to-end model pipeline and deliverable for business consumption

Perform any other job related duties as requested

Qualification

Data analysisSQLPythonStatistical analysisPredictive modelingMachine learningHealthcare experienceData visualizationFeature engineeringCritical thinkingVerbal communicationWritten communicationCollaboration

Required

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

Three (3) years data analysis and/or analytic programming required

Healthcare experience required

Proficient in SQL and at least one of the following programming languages: Python / R / RAT STAT

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

Working knowledge of predictive modeling and machine learning algorithms such as generalized linear models, non-linear supervised learning models, clustering, decision trees, dimensionality reduction and natural language processing

Proficient in feature engineering techniques and exploratory data analysis

Ability to analyze large quantities of information and identify patterns, irregularities, and deficiencies

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

Demonstrated critical thinking, verbal communication, presentation and written communication skills

Ability to work independently and within a cross-functional team environment

Preferred

Experience with cloud services (such as Azure, AWS or GCP) and modern data stack (such as Databricks or Snowflakes) preferred

Familiarity with SAS is preferred

Preferred beginner level of knowledge of developing reports or dashboards in Power BI or other business intelligence applications

Knowledge of healthcare coding and billing processes, including CPT4, HCPCS, ICD-9, DRG and Revenue Codes preferred

Benefits

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

A 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

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Trends of Total Sponsorships

2025 (30)

2024 (39)

2023 (35)

2022 (21)

2021 (37)

2020 (28)