Senior Manager, Program Integrity Data Science

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 Care Source health plans.

• 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 Care Source 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…