The Program Integrity Data Scientist III is responsible for leading the design, development, and deployment of advanced analytical solutions that support payment accuracy, anomaly detection, and Fraud, Waste, and Abuse (FWA) prevention and recovery efforts. This role serves as a senior analytical resource, providing technical leadership across complex investigations, predictive modeling initiatives, and enterprise program integrity strategies while mentoring junior analysts and data scientists.
Essential Functions:
- Lead the design, development, and implementation of advanced algorithms that identify claims for pre- and post-payment intervention related to potential Fraud, Waste, and Abuse.
- Analyze and quantify claim payment issues and provide recommendations to mitigate identified program integrity risks.
- Identify emerging trends, risks, and patterns across multiple healthcare datasets and recommend strategic interventions to improve program integrity outcomes.
- Mentor and provide technical guidance to analysts and data scientists through code reviews, analytical reviews, and best practice recommendations.
- Evaluate emerging analytical, machine learning, and AI techniques to improve fraud detection, anomaly identification, and payment integrity efforts.
- Conduct outcome analyses to determine impact and effectiveness of corporate program and payment integrity initiatives.
- Lead the examination and interpretation of complex data relationships to support payment integrity, anomaly detection, and FWA investigations.
- Lead monitoring and investigation of anomalies and emerging trends associated with potential Fraud, Waste, and Abuse activities across the 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.
- Lead development and communication of analytical strategies, project plans, methodologies, and investigative approaches for complex initiatives.
- Design and develop advanced dashboards, visualizations, and reporting solutions that demonstrate model performance, program effectiveness, and program integrity outcomes.
- Lead development of AI-enabled and business intelligence dashboards that support investigator workflows, fraud detection activities, operational monitoring, and executive decision-making.
- Provide statistical validation and analysis of outcomes associated with clinical programs and interventions.
- Provide technical leadership in integrating analytical solutions with enterprise systems, platforms, and operational workflows.
- Present analytical findings, strategic recommendations, and program integrity insights to leadership and key stakeholders.
- Lead preparation and deployment of production-ready analytical code, models, and automated decision-support solutions.
- Research policy, billing guidelines, CMS direction and others to ideate new fraud, waste and abuse concepts to implement.
- Perform any other job related duties as requested.
Education and Experience:
- 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
- Five (5) years data analysis and/or analytic programming required
- One (1) year Experience with cloud services (such as Azure, AWS or GCP) and modern data stack (such as Databricks or Snowflake) preferred
- Healthcare experience required
- Experience supporting payment integrity, fraud detection, audit recovery, SIU, or program integrity initiatives preferred
- Experience developing and applying deep learning, neural network, graph analytics, or graph neural network (GNN) solutions for fraud detection, anomaly identification, payment integrity, or healthcare analytics initiatives preferred
- Advanced proficiency in SQL and at least one programming language such as Python or R
- Familiarity with SAS is preferred
- Proficient in designing and developing dashboards and reporting solutions using Power BI or similar business intelligence platforms
- Ability to perform advanced statistical analyses and techniques including t-tests, ANOVAs, z-tests, statistical extrapolations, non-parametric significance testing, and sampling methodologies
- Advanced knowledge of predictive modeling, machine learning, deep learning, neural networks, graph analytics, graph neural networks (GNNs), clustering, dimensionality reduction, anomaly detection, and natural language processing
- Proficient in feature engineering techniques and exploratory data analysis
- Ability to apply advanced analytical, artificial intelligence, and graph-based techniques to identify complex provider, member, claim, and organizational relationships associated with payment integrity, Fraud, Waste, and Abuse (FWA), anomaly detection, and recovery opportunities
- Ability to analyze large quantities of information and identify patterns, irregularities, and deficiencies
- Strong knowledge of healthcare coding, billing processes, reimbursement methodologies, claims adjudication and Program Integrity concepts.
- Proficient with MS office (Excel, PowerPoint, Word, Access)
- Demonstrated critical thinking, verbal communication, presentation and written communication skills
- Ability to independently lead analytical initiatives and collaborate effectively across cross-functional teams
- Familiarity with developing AI-enabled analytical solutions supporting fraud detection, anomaly identification, and payment integrity operations
- Ability to mentor analysts and data scientists through analytical reviews, statistical guidance, and technical coaching
- None
- 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:
$94,100.00 - $164,800.00CareSource 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):
SalaryOrganization Level Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
Skills Required
- Bachelor's degree in Data Science, Mathematics, Statistics, Engineering, Computer Science, or a related field
- Equivalent relevant work experience may substitute for the required degree
- Five years of data analysis and/or analytic programming experience
- One year of experience with cloud services such as Azure, AWS, or GCP and modern data stacks such as Databricks or Snowflake
- Healthcare experience
- Experience supporting payment integrity, fraud detection, audit recovery, SIU, or program integrity initiatives
- Experience developing and applying deep learning, neural network, graph analytics, or graph neural network solutions for fraud detection, anomaly identification, payment integrity, or healthcare analytics
- Advanced proficiency in SQL and at least one programming language such as Python or R
- Familiarity with SAS
- Experience designing and developing dashboards and reporting solutions using Power BI or similar business intelligence platforms
- Advanced statistical analysis skills, including hypothesis testing, statistical extrapolation, significance testing, and sampling methodologies
- Advanced knowledge of predictive modeling, machine learning, deep learning, neural networks, graph analytics, graph neural networks, clustering, dimensionality reduction, anomaly detection, and natural language processing
- Proficiency in feature engineering and exploratory data analysis
- Knowledge of healthcare coding, billing processes, reimbursement methodologies, claims adjudication, and program integrity concepts
- Proficiency with Microsoft Office, including Excel, PowerPoint, Word, and Access
- Critical thinking, verbal communication, presentation, and written communication skills
- Ability to independently lead analytical initiatives and collaborate across cross-functional teams
- Ability to mentor analysts and data scientists through analytical reviews, statistical guidance, and technical coaching
CareSource Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about CareSource and has not been reviewed or approved by CareSource.
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Strong & Reliable Incentives — Bonuses are regularly available and serve as a meaningful part of total compensation. Annual performance-based awards are considered a strong component.
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Leave & Time Off Breadth — PTO starts around four weeks and increases with tenure, complemented by paid holidays and a floating day. Volunteer time expands the available leave options.
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Affordable Benefits — Health plan options are considered affordable, supported by wellness incentives that can reduce premiums. Coverage breadth includes medical, dental, vision, and cost‑lowering programs.
CareSource Insights
What We Do
Health Care with Heart. It is more than a tagline; it’s how we do business. CareSource has been providing life-changing health care to people and communities for nearly 30 years and we will continue to be a transformative force in the industry by placing people over profits. CareSource is and will always be members first. Even as we grow, we remember the reason we are here – to make a difference in our members’ lives by improving their health and well-being. Today, CareSource offers a lifetime of health coverage to nearly 2 million members through plan offerings including Marketplace, Medicare Advantage and Medicaid. With our team of 4,000 employees located across the country, we continue to clear a path to better life for our members. Visit the "Life" section to see how we are living our mission in the states we serve. CareSource is an equal opportunity employer and gives consideration for employment to qualified applicants without regard to race, color, religion, sex, age, national origin, disability, sexual orientation, gender identity, genetic information, protected veteran status or any other characteristic protected by applicable federal, state or local law. If you’d like more information about your EEO rights as an applicant under the law, please click here: https://www.eeoc.gov/employers/upload/poster_screen_reader_optimized.pdf and here: https://www.dol.gov/ofccp/regs/compliance/posters/pdf/OFCCP_EEO_Supplement_Final_JRF_QA_508c.pdf Si usted o alguien a quien ayuda tienen preguntas sobre CareSource, tiene derecho a recibir esta información y ayuda en su propio idioma sin costo. Para hablar con un intérprete, Por favor, llame al número de Servicios para Afiliados que figura en su tarjeta de identificación. 如果您或者您在帮助的人对 CareSource 存有疑问，您有权 免费获得以您的语言提供的帮助和信息。 如果您需要与一 位翻译交谈，请拨打您的会员 ID 卡上的会员服务电话号码
