Cohere Health is looking to solve the problem of healthcare fraud, waste, and abuse by applying optimization and statistical methods on a variety of data to support decision-making and drive strategic data science initiatives.
Requirements
- Expert in conducting data mining in the healthcare insurance industry and claims-related experience and knowledge of coding, reimbursement, and claims processing policies
- Knowledge of the law and regulations as it relates to FWA investigations and familiar with CMS medicare and medicaid policies
- Proficient in current modeling approaches, standard scientific methods for intervention based analysis, trend identification, causal inference, and pattern detection
- Strong experience using a variety of data mining/data analysis methods, utilizing a variety of analytic tools, building and implementing models, creating algorithms and running simulations
- Experience with programming languages (Python,PySpark, Scala and/or Spark SQL)
- Experience with graph database managing clinical concept is a big plus
- MSc or higher degree in a data science/ analytics, statistics, mathematics, engineering related field
Responsibilities
- Drive strategic data science initiatives that focus on healthcare fraud, waste and abuse including identification, investigation, validation, escalation and prevention
- Performs proactive fraud, waste and abuse detection analysis derived from various monitoring based data sources
- Serve as a subject matter expert on identifying and discovering claim and authorization outliers and interpret and analyze data to accurately assess and demonstrate key insights into trends and opportunities.
- Independently lead in-depth analyses of a variety of healthcare and product data sources to investigate suspicious activities, and prepares detailed reports of their findings
- Stay up-to-date with the latest industry trends, regulatory changes, and emerging fraud schemes to enhance detection strategies.
- Present information using data visualization techniques and propose solutions and strategies to business challenges
- Translate business needs from stakeholders into data science technical requirements and translate data science results back to business and clinical units.
Other
- MSc or higher degree in a data science/ analytics, statistics, mathematics, engineering related field
- 7+ years hands-on data science experience at company where health outcome performance were critical to the mission, preferably a healthcare insurance company
- Strong communication skills with the unique ability to translate business needs from stakeholders into data science technical requirements and translate data science results back to business and clinical units.
- About x% travel
- Up to 184 hours (23 days) of PTO per year + company holidays
