Job Summary:

The Senior Manager, Program Integrity Data Science will oversee the Program Integrity Data Science team, serving as both a subject matter expert and a mentor. This role is accountable for designing and implementing algorithms that identify claims for intervention (audit, downcode, edit, etc.) – driving claim payment accuracy and mitigating fraud, waste, and abuse (FWA) within CareSource health plans.

Essential Functions:

• 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.

Education and Experience:

• 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

Competencies, Knowledge and Skills:

• 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

Licensure and Certification:

• 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

Working Conditions:

• 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:

$110,800.00 - $193,800.00

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):

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

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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