Hi, we're Oscar. We're hiring an Associate, Itemized Bill Review to join our Payment Integrity team.

Oscar is the first health insurance company built around a full stack technology platform & a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselvesone that behaves like a doctor in the family.

About the role:

The Associate, Payment Integrity, Itemized Bill Review (IBR) will be responsible for executing internal payment integrity solutions requiring billing & coding expertise with & continual improvement & development of the solutions. You will ensure claims are paid accurately & timely with the highest quality. This is accomplished by leveraging a deep understanding of Oscar's claim infrastructure, workflows, workflow tooling, platform logic, data models, etc., to work cross-functionally to understand & translate friction from stakeholders into actionable opportunities for improvement.

You will report into the Manager, Payment Integrity (Pre-Pay).

Work Location: This position is based in our New York City office, requiring a hybrid work schedule with 3 days of in-office work per week. Thursdays are a required in-office day for team meetings & events, while your other two office days are flexible to suit your schedule. #LI-Hybrid

Pay Transparency: The base pay for this role is: $88,800 - $116,550 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program, & annual performance bonuses.

Responsibilities:

• Perform line-by-line review of high-dollar facility itemized bills & corresponding claim forms (e.g., UB-04s)
• Proactively identify & 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) & charges for non-covered or non-rendered services
• Compare billed charges against both payor-specific contracts & 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, & professional documentation of all findings, including savings identified, policy violations, & recommended claim adjustments
• Contribute to the refinement of internal audit processes & tools to enhance efficiency & accuracy in identifying claim inaccuracies
• Serve as a subject matter expert for internal & external stakeholders regarding complex billing issues, coding guidelines, & payor policies
• Provide subject matter expertise & in-depth understanding of Payment Integrity internal claims processing edits, external vendor edits & Oscar reimbursement policies
• Identify claims payment issues from data mining, process monitoring, etc., provide scoping & action steps needed to remediate the issue
• Respond to internal & external inquiries & disputes regarding policies & edits.
• Document industry standard coding rules & provide recommendations on reimbursement policy language & scope
• Ideate payment integrity opportunities based on a deep knowledge of industry standard coding rules. Translate into business requirements; submit to & collaborate with internal partners to effectuate change
• Provide training & education to team members when necessary
• Perpetuate a culture of transparency & 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 & assigned by leadership
• Compliance with all applicable laws & regulations
• Other duties as assigned

Requirements:

• 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 & common claims processing/resolution practices

Bonus points:

• 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