Hi, we're Oscar. Were hiring a Claims Review Nurse to join our Special Investigations Unit (SIU).
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 SIU runs or coordinates activities across Oscar to reduce the incidence & impact of fraud, waste, and/or abuse (FWA) on all our operations.
Within the SIU, your primary role will be to support Oscar in its fight against fraud. Joining this dynamic team will expose you to the latest trends & patterns in FWA across the healthcare industry & provide you with the chance to fight this FWA using your deep coding knowledge to prevent & recoup inappropriately paid claims. Your work will not only lead to savings & recoupments for Oscar as a company, but to more affordable & higher-quality health care for the members we serve.
You will report into the SIU Director, who reports to the Compliance Officer.
Primary Duties & Responsibilities
Efficiently perform thorough & complex coding reviews of medical records & claims on both a prepayment & post payment basis to determine accuracy of claims submitted to Oscar.
When assigned, following coding reviews, perform thorough & complex clinical reviews of medical records & claims & apply appropriate evidence-based guidelines & medical policy.
Explicitly & concisely document both coding & clinical findings including sources used to support decision making, & in a way that can be easily understood by non clinicians & non coders.
Meet required decision-making timeframes with the quality standards established within the department.
Clearly document all communication & decision making within the prepay review platform or the assigned audit template, ensuring your peers could easily reference & understand your decision.
Demonstrate the highest level of professionalism, accountability, & service in your interactions with Oscar teammates, providers, & members.
Other duties as assigned include but are not limited to: assisting with new team member training, participation in improving Oscars overall operations, reviewing findings letters to ensure clarity, & providing insight to the data team on their findings.
Maintain continued professional growth & education to meet continuing education requirements & demonstrate knowledge & understanding of current coding & nursing care practice.
Required education & experience
- 5+ years of healthcare experience to include a combination of clinical nursing practice & utilization review or auditing.
- 2+ years of coding or auditing experience across multiple specialties.
Active, unrestricted RN or BSN license
Certified Professional Coder (CPC) designation or similar
Highly organized with a high level of attention to detail
Enjoy detailed research on complex coding & clinical schemes that may be used to inappropriately enhance reimbursement to providers or facilities.
Clear ability to translate technical jargon to non-technical end users
Preferred education & experience
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] & Fraud Professional (CAFP), other coding certifications or similar
Knowledge of applicable fraud statutes & regulations, & of federal guidelines on recoupments & other anti-FWA activity
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
Life at Oscar:
At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves & find both belonging & support. We're on a mission to change health care -- an experience made whole by our unique backgrounds & perspectives.
We encourage our members to care for their whole selves, & we encourage our employees to do the same with comprehensive medical benefits, generous paid-time off, paid parental leave, retirement plans, company social events, stocked kitchens, wellness programs, & volunteer opportunities.
Oscar applicants are considered solely based on their qualifications, without regard to applicants disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (firstname.lastname@example.org) to make the need for an accommodation known.
Pay Transparency Policy:
Oscar ensures that you won't be discharged or discriminated against based on whether you've inquired about, discussed, or disclosed your pay. Read the full policy here.
COVID-19 vaccine requirements for in-person work:
To protect the health & safety of our employees, we require any employee conducting in-person work* to be fully vaccinated against COVID-19 by their start date.
If you are unable to be vaccinated due to medical or protected religious reasons, please reach out to our Benefits team at email@example.com to submit an accommodations request.
*Note: In-person work includes: employees required to work from our offices (either full-time or part-time), employees conducting sales work in the field & employees conducting at-home or in-person visits with members.