Associate, Payment Integrity IBR

Summary

Oscar is a health insurance company built around a full-stack technology platform and a focus on serving its members. The Associate, Payment Integrity, Itemized Bill Review role reviews facility bills and claims, identifies billing and coding errors, validates reimbursement practices, and collaborates with stakeholders to improve payment integrity processes.

Responsibilities

• Perform line-by-line review of high-dollar facility itemized bills and corresponding claim forms (e.g., UB-04s)
• Proactively identify and document potential billing errors, including duplicate billing of items, services, or procedures as improper unbundling of services (e.g., separating components that should be billed together) and charges for non-covered or non-rendered services
• Compare billed charges against both payor-specific contracts and industry guidelines to confirm appropriate billing practices
• Apply working knowledge of national coding systems (e.g., CPT, HCPCS, ICD-10, MS-DRGs) to validate the accuracy of codes used for services billed
• Review claims eligible under specific reimbursement scenarios: a percentage of charges or those exceeding stop-loss levels, ensuring the claim exceeds the minimum dollar threshold set by the payor
• Prepare clear, concise, and professional documentation of all findings, including savings identified, policy violations, and recommended claim adjustments
• Contribute to the refinement of internal audit processes and tools to enhance efficiency and accuracy in identifying claim inaccuracies
• Serve as a subject matter expert for internal and external stakeholders regarding complex billing issues, coding guidelines, and payor policies
• Provide subject matter expertise and in-depth understanding of Payment Integrity internal claims processing edits, external vendor edits and Oscar reimbursement policies
• 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 language and scope
• 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

Skills

• A bachelor's degree or 4+ years of commensurate experience
• 2+ years of bill / coding audit experience with a focus on hospital or facility billing (UB-04)
• 4+ 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
• 3+ years of experience working with large data sets using excel or a database language
• Knowledge management, training, or content development in operational settings
• Process Improvement or Lean Six Sigma training
• Experience using SQL

Qualifications

Must Haves

• A bachelor's degree or 4+ years of commensurate experience
• 2+ years of bill / coding audit experience with a focus on hospital or facility billing (UB-04)
• 4+ 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

Nice to Haves

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

Benefits

• Fully remote position for candidates residing in Atlanta, Georgia; Chicago, Illinois; Dallas, Texas; Louisville, Kentucky; Minneapolis, Minnesota; Philadelphia, Pennsylvania; or Salt Lake City, Utah
• Potential future hybrid presence at the hub office associated with your metro area
• Employee benefits
• Oscar's unlimited vacation program
• Annual performance bonuses
• Medical, dental, and vision benefits for full-time employees
• 11 paid holidays
• Paid sick time
• Paid parental leave
• 401(k) plan participation
• Life and disability insurance
• Paid wellness time and reimbursements