Senior Manager, Program Integrity Data Science

• 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. Algorithms will vary from rule / criteria-based solutions to probabilistic scoring / statistical solutions and will include a ranking of relative value / likelihood of fraud, waste, or abuse.
• 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.

• Bachelor's degree in Data Science, Mathematics, Statistics, Criminal Justice, Medical/Health Care Field, or another related field required
• Master's degree in Data Science, Mathematics, Statistics, Criminal Justice, Medical/Health Care Field, or another related field preferred
• Equivalent years of relevant work experience may be accepted in lieu of required education
• 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
• 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

• General office environment; may be required to sit or stand for extended periods of time
• Up to 15% (occasional) travel to attend meetings, trainings, and conferences may be required

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business