Senior Specialist, Payment Integrity

Summary

Join Oscar's Payment Integrity team as a Senior Specialist! This role focuses on process improvement and dispute resolution within our payment integrity environment. You will review, investigate, and resolve provider disputes related to claims, payments, and contract terms. Leveraging your deep understanding of Oscar's claim and payment infrastructure, you'll contribute to a culture of transparency and collaboration. This blended work culture offers flexibility, with remote options available depending on location. Competitive pay and a comprehensive benefits package are included.

Requirements

• A bachelor’s degree or 4+ years of commensurate experience
• 4+ years of experience in claims processing, coding, auditing or health care operations
• 3+ years experience in medical coding
• 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
• 2+ years experience deriving business insights from datasets and solving problems
• 1+ years experience improving business workflows and processes
• 1+ years experience collaborating with internal and/or external stakeholders

Responsibilities

• Contribute as a subject matter expert for Oscar reimbursement policies, payment integrity internal claims processing edits and external vendor edits
• Respond to internal and external inquiries and disputes regarding policies and edits
• Research industry standard coding rules, summarize and provide input into reimbursement policy language and scope
• Use knowledge gained through research and claims review to ideate payment integrity opportunities. Translate into business requirements; submit to and collaborate with internal partners to effectuate change
• Ingest information from internal and external partners regarding adverse claim outcomes; collaborate with partners to scope, size, prioritize items and deliver solutions
• Use insights from partner submissions, data mining, process monitoring, etc., work with the team to proactively identify thematic areas of opportunity to solve problems
• 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

• 2+ years experience in a technical role (QA analyst, PM, operations analyst, finance, consulting, industrial engineering) or a process improvement role (Six Sigma or similar)
• 2+ years of experience working with large data sets using excel or a database language
• 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
• Annual performance bonuses
• Oscar's unlimited vacation program