Associate, Payment Integrity

Summary

Join Oscar's Payment Integrity team as an Associate and support process improvement and issue resolution in the Oscar claim environment. You will ensure claims are paid accurately and timely by analyzing data and auditing policies. Leverage your understanding of Oscar’s claim infrastructure, payment policies, and regulatory guidelines to identify improvement opportunities. Collaborate cross-functionally to implement changes and provide thought leadership for Payment Integrity processes. This role requires a deep understanding of Anesthesia billing and coding and involves working with large datasets. The position offers a blended work culture with remote options and competitive compensation and benefits.

Requirements

• A bachelor’s degree or 4+ years of commensurate experience
• 4+ years of experience in claims processing, coding, auditing or health care operations
• 4+ years experience in medical coding and deep understanding of Anesthesia coding guidelines
• Medical coding certification through AAPC (CPC, COC) or AHIMA (CCS, RHIT, RHIA)
• Experience with reimbursement methodologies, provider contract concepts and common claims processing/resolution practices
• 3+ year(s) ability to work independently to drive projects to completion

Responsibilities

• Provide subject matter expertise and in-depth understanding of Payment Integrity internal claims processing edits, external vendor edits, Oscar reimbursement policies with a specialized focus on Anesthesia billing and coding
• Identify claims payment issues from data mining, process monitoring, etc., provide scoping and action steps needed to remediate the issue
• Respond to internal and external inquiries and disputes regarding policies and edits
• Document industry standard coding rules and provide recommendations on reimbursement policy, edit logic, and creating and building exclusions
• Ideate payment integrity opportunities based on a deep knowledge of industry standard coding rules. Translate into business requirements; submit to and collaborate with internal partners to effectuate change
• Provide training and education to team members when necessary
• Perpetuate a culture of transparency and collaboration by keeping stakeholders well informed of progress, status changes, blockers, completion, etc.; field questions as appropriate
• Support Oscar run state objectives by providing speedy research, root cause analysis, training, etc. whenever issues are escalated and assigned by leadership
• Compliance with all applicable laws and regulations
• Other duties as assigned

Preferred Qualifications

• 3+ years of experience working with large data sets using excel or a database language
• Experience coaching and training team members
• Experience in a professional healthcare claims organization
• Knowledge management, training, or content development in operational settings
• Process Improvement or Lean Six Sigma training
• Experience using SQL

Benefits

• Medical, dental, and vision benefits
• 11 paid holidays
• Paid sick time
• Paid parental leave
• 401(k) plan participation
• Life and disability insurance
• Paid wellness time and reimbursements