Lead Data Scientist- Fraud, Waste & Abuse at Cohere Health

, , United States -

Full Time

Start Date

Immediate

Expiry Date

01 Jan, 26

Salary

168000.0

Posted On

03 Oct, 25

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Data Science, Fraud Detection, Waste Prevention, Statistical Methods, Data Analysis, Healthcare Insurance, Claims Processing, Data Mining, Python, PySpark, Scala, Spark SQL, Graph Database, Causal Inference, Trend Identification, Pattern Detection

Industry

Software Development

Description

Opportunity Overview: We are looking for innovative and creative individuals who seize opportunities to uncover hidden drivers, impacts, and key influences to support our product, leadership and clinical teams by applying optimization and statistical methods on a variety of data. You will work closely with the clinical program and product teams to support decision-making and will dig into a wide range of strategic and clinical problems. As a growing organization, we have built a team of talented and experienced people who are passionate about helping providers and patients and this is a position that offers the ability to make a substantial impact on the company with rapid growth opportunities. You will be part of a growing data science team within the technology organization. What you’ll do: 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. This role requires maintaining meticulous methodology documentation and presenting findings or recommendations to leadership group 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. Present information using data visualization techniques and propose solutions and strategies to business challenges What you’ll need: 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 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 Pay & Perks: 💻 Fully remote opportunity with about x% travel 🩺 Medical, dental, vision, life, disability insurance, and Employee Assistance Program 📈 401K retirement plan with company match; flexible spending and health savings account 🏝️ Up to 184 hours (23 days) of PTO per year + company holidays 👶 Up to 14 weeks of paid parental leave 🐶 Pet insurance The salary range for this position $148,000 to $168,000 annually; as part of a total benefits package which includes health insurance, 401k and bonus. In accordance with state applicable laws, Cohere is required to provide a reasonable estimate of the compensation range for this role. Individual pay decisions are ultimately based on a number of factors, including but not limited to qualifications for the role, experience level, skillset, and internal alignment. Interview Process*: Connect with Talent Acquisition for a Preliminary Phone Screening Meet your Hiring Manager! Take Home Assessment Case Study Presentation Behavioral Interviews *Subject to change About Cohere Health: Cohere Health’s clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. Cohere Health works with over 660,000 providers and handles over 12 million prior authorization requests annually. Its responsible AI auto-approves up to 90% of requests for millions of health plan members. With the acquisition of ZignaAI, we’ve further enhanced our platform by launching our Payment Integrity Suite, anchored by Cohere Validate™, an AI-driven clinical and coding validation solution that operates in near real-time. By unifying pre-service authorization data with post-service claims validation, we’re creating a transparent healthcare ecosystem that reduces waste, improves payer-provider collaboration and patient outcomes, and ensures providers are paid promptly and accurately. Cohere Health’s innovations continue to receive industry wide recognition. We’ve been named to the 2025 Inc. 5000 list and in the Gartner® Hype Cycle™ for U.S. Healthcare Payers (2022-2025), and ranked as a Top 5 LinkedIn™ Startup for 2023 & 2024. Backed by leading investors such as Deerfield Management, Define Ventures, Flare Capital Partners, Longitude Capital, and Polaris Partners, Cohere Health drives more transparent, streamlined healthcare processes, helping patients receive faster, more appropriate care and higher-quality outcomes. The Coherenauts, as we call ourselves, who succeed here are empathetic teammates who are candid, kind, caring, and embody our core values and principles. We believe that diverse, inclusive teams make the most impactful work. Cohere is deeply invested in ensuring that we have a supportive, growth-oriented environment that works for everyone. We can’t wait to learn more about you and meet you at Cohere Health! Equal Opportunity Statement: Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all. To us, it’s personal. #LI-Remote #BI-Remote

Responsibilities

Drive strategic data science initiatives focusing on healthcare fraud, waste, and abuse. Independently lead in-depth analyses of healthcare and product data sources to investigate suspicious activities.