Full-Time
Lead Data Scientist-Fraud
Waste & Abuse
Posted on 10/3/2025
Cohere Health
501-1,000 employees
Digital health PaaS automating prior authorization
Compensation Overview
$148k - $175k/yr
Remote in USA
Remote
Fully remote; ~5% travel.
 Data & Analytics (1) |
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- MSc or higher degree in a data science/ analytics, statistics, mathematics, engineering related field
- 7+ years hands-on data science experience at a 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.
- 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 fraud, waste and abuse 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
- Experience with Amazon AWS cloud platform is a plus
- Drive strategic data science initiatives that focus on preventing and identifying healthcare fraud, waste and abuse.
- Serve as a subject matter expert on identifying and discovering claim and authorization outliers and interpret and analyze data to 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
- Present information using data visualization techniques and propose solutions and strategies to business challenges
Cohere Health provides a Platform-as-a-Service to streamline prior authorization in healthcare. Its Cohere Unify platform digitizes requests into a single automated workflow, integrates with electronic medical records, and uses OCR for fax submissions. It uses machine learning and responsible AI to automate decisions based on health plan policies, speeding reviews and ensuring complete information. The company licenses Cohere Unify to health plans for use by internal utilization management teams, aiming to reduce delays, cut costs, and improve patient outcomes.
Company Size
501-1,000
Company Stage
Series C
Total Funding
$196M
Headquarters
Boston, Massachusetts
Founded
2019
Simplify's Take
What believers are saying
- Geisinger Health Plan achieved 15% medical expense reduction and 63% PA denial drop post-deployment.
- Cohere Surface launched April 28, 2026, delivers 9x ROI via agentic AI overpayment detection.
- Dr. Mark Leenay joined board February 24, 2026, bolstering health plan partnerships and clinical AI.
What critics are saying
- Cotiviti and Optum erode Cohere's payment integrity share with superior scale within 12-24 months.
- AI auto-approvals trigger lawsuit over denied care, causing payer exodus in 18-36 months.
- Naming overlap with Cohere.com confuses clients, diluting B2B leads in 3-6 months.
What makes Cohere Health unique
- Cohere Health's clinical intelligence platform auto-approves 90% of prior authorizations using clinician-crafted AI.
- Cohere Unify integrates EMRs and OCR for seamless payer-provider prior authorization workflows.
- Payment Integrity Suite with Cohere Validate unifies pre- and post-service claims validation in real-time.
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Benefits
Health Insurance
401(k) Company Match
Performance Bonus
Remote Work Options
Growth & Insights and Company News
6 month growth
↑ 0%1 year growth
↑ 1%2 year growth
↑ 2%Cohere Health has appointed Dr Mark Leenay to its board of directors. Dr Leenay brings over 20 years of healthcare experience, including senior roles at WellCare, Optum and UnitedHealthcare, alongside expertise in medical cost management and health plan operations. The board-certified physician in family medicine and geriatrics previously served as COO of ChenMed, CEO of InHealth MD Alliance and EVP and Chief Medical Officer of WellCare Health Plans. He also held executive positions at UnitedHealth Group for a decade. Cohere Health develops clinical intelligence platforms and AI-powered solutions for health plans and providers. The company reports achieving eight times return on investment and 94% provider satisfaction with its enterprise platform that streamlines payer-provider decision-making across prior authorisation, payment accuracy and appeals.
Cohere Health adds Dr. Mark Leenay to board of directors to advance clinical AI leadership and health plan collaborations. Published: February 24, 2026 Physician and healthcare executive brings expertise in medical cost management and health plan operations to support the company's growth. BOSTON (February 24, 2026) - Cohere Health(R) today announced the appointment of Dr. Mark Leenay to its board of directors. Dr. Leenay brings extensive leadership experience across medical cost management, clinical program development, and health plan operations, including senior roles at WellCare, Optum, and UnitedHealthcare. Dr. Leenay's addition to the board deepens Cohere Health's strategic expertise as the company scales partnerships with innovative health plans and advances clinically led AI. As a strategic advisor to national and regional health plans, Dr. Leenay guides organizations on clinical and operational strategy. He is a board-certified physician in family medicine and geriatrics and brings a unique combination of clinical insight and executive leadership in patient care, payment programs, and medical cost optimization. "Dr. Leenay's appointment comes at a pivotal time as Cohere Health continues building momentum with our domain-specific, agentic AI and enterprise clinical intelligence platform," said Siva Namasivayam, CEO of Cohere Health. "He brings a rare perspective that combines physician-level clinical insights with executive health plan leadership - strategically aligned to our mission to help health plans transform decision-making throughout the care continuum." "I believe clinically trained AI can make a meaningful difference in supporting patient care," Dr. Mark Leenay shared. "As a member of the board of directors, I look forward to supporting Cohere Health's mission by connecting health plans and providers to improve efficiency and address the challenges of rising healthcare costs." Dr. Leenay brings more than 20 years of healthcare experience to Cohere Health, including health plan leadership, operational expertise, and an extensive clinical and academic background. He previously served as COO of ChenMed, CEO of InHealth MD Alliance, and EVP and Chief Medical Officer of WellCare Health Plans, and spent a decade in executive leadership positions at UnitedHealth Group. He earned his Doctor of Medicine from Thomas Jefferson University. "Dr. Leenay's experience and insights as both a physician and health plan leader significantly strengthen Cohere Health's governance and strategic direction, supporting our efforts to advance payer-provider collaboration so patients receive the right care, in the right place, at the right time," notes Dr. Gary Gottlieb, executive chair of Cohere Health. About Cohere Health Cohere Health's clinical intelligence platform and agentic AI-powered solutions connect health plans' strategic goals and providers' needs, optimizing the speed, cost, and quality of care. With an enterprise approach that streamlines payer-provider decision-making across the care continuum - including policy, prior authorization, payment accuracy, and more - the company improves collaboration and reduces burden, resulting in 8x ROI and 94% provider satisfaction. Cohere Health is recognized on TIME's World's Top HealthTech Companies 2025 list, on the 2025 Inc. 5000 list, and by numerous industry analysts. Stay ahead with expert insights on transforming utilization management and payment integrity - delivered straight to your inbox.
Veteran healthcare leader Cathy Fackovec joins Cohere Health to advance Clinical Operations. Fackovec's appointment as EVP and GM of Clinical Operations reinforces Cohere Health's commitment to clinically led innovation as it expands technology-enabled collaboration. BOSTON (January 8, 2026) - Cohere Health(R), the leader in clinical intelligence solutions for health plans, today announced the appointment of Cathy Fackovec as Executive Vice President and General Manager of Clinical Operations. With more than 30 years of clinical leadership and healthcare operations experience, Fackovec will lead the execution and scaling of Cohere Health's clinical operations and service operations teams. In this role, Fackovec will focus on strengthening Cohere Health's clinical operating model - ensuring clinical expertise, operational rigor, and technology are aligned to support effective payer-provider collaboration and timely access to appropriate, high-quality care. Fackovec's work is enabled by Cohere Health's deep bench of expert clinicians, a 220-member team that includes more than 70 MDs across high-impact specialties like musculoskeletal care, cardiology, radiology, sleep medicine, and more - areas that together represent about 60% of U.S. healthcare spend. "Cathy is a seasoned clinical and operational leader with proven expertise in building and scaling robust healthcare organizations," said Siva Namasivayam, CEO of Cohere Health. "Her leadership will be instrumental as we expand our clinical capabilities and help clients navigate an increasingly complex healthcare ecosystem. What truly differentiates Cohere Health is our team of clinician experts, who help build and continuously improve our AI-powered platform every day - working alongside our health plan partners and their providers to improve member care and outcomes." Fackovec brings experience spanning health plans, provider organizations, and post-acute care. Prior to joining Cohere Health, she held executive leadership roles at naviHealth (acquired by Optum in 2020) and Tomorrow Health - including Senior Vice President of Utilization Management and Clinical Operations, and Market President - where she led multi-state clinical teams and drove measurable improvements in efficiency, quality, and care outcomes. Earlier in her career, Fackovec began in direct patient care and healthcare operations at Allegheny Health Network, which continues to shape her patient-centric, data-driven approach to leadership. "I am excited to join Cohere Health at a pivotal moment for the industry," said Fackovec. "As health plans and providers increasingly adopt automation and AI to support healthcare decision-making and operations, strong clinical leadership is essential. Cohere Health's commitment to transparent, evidence-based decision-making and meaningful collaboration across the ecosystem strongly aligns with my passion for improving access and outcomes through smart, scalable operations." This appointment underscores Cohere Health's continued investment in a clinically led operating model to drive impact for its health plan clients. The company's clinical teams play a central role in ensuring alignment with the latest evidence-based guidelines, collaboration with medical societies, and that expert clinical insight is embedded across its technology and AI-driven workflows. 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 AI auto approves up to 90 percent of requests for millions of health plan members. The company has been recognized on the 2025 Inc. 5000 list, the Deloitte Technology Fast 500(TM), in the Gartner(R) Hype Cycle(TM) for U.S. Healthcare Payers, and as a Top 5 LinkedIn(TM) Startup for 2023 & 2024. Stay ahead with expert insights on transforming utilization management and payment integrity - delivered straight to your inbox.
Cohere Health Policy Studio(TM) accelerates interoperability and policy management for health plans. * By Cohere Health * Dec 9, 2025 Updated Dec 9, 2025 BOSTON, Dec. 9, 2025 /PRNewswire/ - Cohere Health(R), the leader in clinical intelligence solutions for health plans, announced the launch of Cohere Policy Studio(TM), a comprehensive medical policy management solution that automates how health plans create, manage, and deploy clinical policies. This fundamentally new approach turns disconnected, static medical policies into digitized, structured assets that can serve as a single source of truth. Cohere Policy Studio supports more consistent and reliable clinical decision-making, promotes interoperability, and helps enhance compliance and operational efficiency. As the industry faces increasing demand for greater interoperability and transparency, static policy documents present significant operational challenges. Without digitized, structured policies, health plans cannot effectively automate authorization workflows in a meaningful way. Additionally, they can't meet CMS interoperability requirements or fulfill the goals outlined in AHIP's 2025 pledge to standardize electronic prior authorization, enhance transparency, and expand real-time response capabilities. "Health plans are under tremendous pressure to modernize their policy management practices, but the infrastructure to do so simply didn't exist before," said Matt Parker, chief product officer at Cohere Health. "Cohere Policy Studio eliminates the technical complexity and manual burden of policy digitization, so a health plan's policies are automatically configured to support critical workstreams from interoperable authorization workflows to public transparency websites." Policy Studio serves as a centralized hub for the entire policy lifecycle, using precision AI to convert unstructured policy documents (e.g., PDFs) into structured formats, with extensive workflow management and automatic version tracking. Once policies are finalized, Policy Studio powers essential capabilities, including API-ready files for interoperability compliance, procedure code search tools, public policy websites, and automated approval rules for utilization management and automation solutions. By connecting all policy extensions to a single source, Policy Studio minimizes drift that may lead to compliance vulnerabilities and provider frustration. Policy Studio, designed to help health plans move beyond basic compliance to achieve operational excellence, is now available. Learn more at coherehealth.com/utilization-management/policy-studio. 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 AI auto-approves up to 90% of requests for millions of health plan members. The company has been recognized on the 2025 Inc. 5000 list, the Deloitte Technology Fast 500(TM), in the Gartner(R) Hype Cycle(TM) for U.S. Healthcare Payers (2022-2025), and is a Top 5 LinkedIn(TM) Startup for 2023 & 2024. View original content to download multimedia:https://www.prnewswire.com/news-releases/cohere-health-policy-studio-accelerates-interoperability-and-policy-management-for-health-plans-302635736.html SOURCE Cohere Health
Cohere Health named "Best in Class - AI in Health Operations" at the 2025 Digital Health awards at HLTH. October 21, 2025 BOSTON (October 21, 2025) - Cohere Health(R), the leader in clinical intelligence solutions for health plans, has been awarded "Best in Class - AI in Health Operations" at the 2025 Digital Health Hub Foundation Awards. The honor recognizes Cohere Health's leadership in applying clinically trained AI to improve payer-provider collaboration, reduce administrative burden, and accelerate access to appropriate, evidence-based care. Selected from more than 1,800 submissions, the Digital Health Hub Foundation's annual awards program celebrates companies making measurable strides in improving healthcare speed, efficiency, and equity through digital innovation. Cohere Health was recognized before an audience of global healthcare leaders, investors, and innovators at HLTH 2025. "We are honored to be recognized for our advancements in healthcare AI among so many innovative companies," said Siva Namasivayam, founder and CEO of Cohere Health. "Cohere Health was founded to transform how care decisions are made and delivered. This achievement affirms our mission to simplify healthcare through clinically trained, responsible AI that helps payers and providers work together more effectively and, most importantly, helps patients get the care they need, faster." Cohere Health's clinical-AI powered platform automates up to 90% of prior authorization requests, aligning each decision with evidence-based guidelines and clinical nuance to eliminate administrative friction, inefficiencies, and inappropriate care. Health plans using Cohere Health's clinical intelligence platform report 70% faster access to care, a 61% reduction in provider input time, and 50% faster medical necessity reviews. These results demonstrate the platform's ability to streamline workflows while maintaining transparency and clinical integrity. "Congratulations to all of our 2025 winners," said Mark H. Goldstein, chairman of the Digital Health Hub Foundation. "Being recognized among thousands of submissions is an incredible accomplishment. Your work sets new standards in healthcare innovation; we are proud to honor your progress and excited to celebrate all the finalists and winners at HLTH." This marks Cohere Health's second consecutive year of recognition by the Digital Health Hub Foundation. In 2024, the company received the Best AI Story award for its responsible AI approach to simplifying healthcare decision-making and enabling more efficient care delivery. For more information about Cohere Health, visit coherehealth.com 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 AI auto-approves up to 90% of requests for millions of health plan members. The company has been recognized on the 2025 Inc. 5000 list and in the Gartner(R) Hype Cycle(TM) for U.S. Healthcare Payers (2022-2025), and is a Top 5 LinkedIn(TM) Startup for 2023 & 2024. About Digital Health Hub Foundation: Its mission is to help the world's next best innovative healthcare companies scale and grow. Founded in 2017, on the campus of UCSF in San Francisco, its now 30,000 member community consists of thousands of early-to late-stage healthcare companies and highly qualified healthcare industry providers, payors, experts, mentors, investors, clinicians and researchers who participate in its annual awards ceremony where Cohere Health, Inc. bring together the industry to honor and validate the best of the best and celebrate the technological advances in healthcare and the impact it has. Stay ahead with expert insights on transforming utilization management and payment integrity - delivered straight to your inbox.