Medical Coding Auditor

Summary

Join Oscar's SIU team as a Medical Coding Auditor, contributing to the assessment of fraud, waste, and abuse (FWA) trends in the healthcare industry. Leveraging your coding expertise, you will audit pre- and post-payment claims, document findings, create reports, and communicate with providers. This role requires a blend of coding knowledge, analytical skills, and communication abilities. The position offers a blended work culture with remote options and a competitive salary and benefits package. You will report to the Associate Director, SIU and must reside in one of the specified states. The base pay varies by location and additional benefits include performance bonuses and unlimited vacation.

Requirements

• 1+ years of coding or auditing experience across multiple specialties
• Bachelor’s degree or 4+ years of work experience

Responsibilities

• Develops and maintains a depth of expertise on CPT, HCPCS, and ICD-10 Coding guidelines and other insurance billing submission requirements
• Perform complex policy updates or audits of assigned documentation (i.e. medical records or claims) on both a prepayment and/or post payment basis to determine accuracy of claims submitted to Oscar
• Document findings including reference to sources used to support decision making and in a way that can be easily understood by non clinicians or coders
• Create reports and reference guides that can be used by other team members to communicate findings or more effectively perform similar reviews
• Help draft written communications to providers to convey findings
• Participate in educational calls with providers
• Help train new team members
• Develop and document processes to improve the effectiveness of the team
• Compliance with all applicable laws and regulations
• Other duties as assigned

Preferred Qualifications

• Certified Professional Coder (CPC) designation or similar certification (required for SIU)
• Certified Professional Medical Auditor
• Additional certification applicable to this work such as Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML [Anti-Money Laundering] and Fraud Professional (CAFP), other coding certifications or similar
• Knowledge of applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity
• Demonstrated experience translating technical jargon to non-technical end users
• Experience working in health insurance specifically with claims processing, billing, reimbursement, or provider contracting
• Experience with HIPAA, data privacy, and/or data security processes
• Experience working with regulators governing (public or private) health insurance carriers

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
• Annual performance bonuses
• Oscar's unlimited vacation program