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 contribute to a team focused on reducing the impact of FWA on Oscar's operations. The role requires experience in coding or auditing and a bachelor's degree or equivalent work experience.

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