Associate, Payment Integrity IBR

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 and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one 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 and coding expertise with and continual improvement and development of the solutions. You will ensure claims are paid accurately and 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 and translate friction from stakeholders into actionable opportunities for improvement. You will report into the Manager, Payment Integrity (Pre-Pay). Work Location: This is a remote position, open to candidates who reside in: Atlanta, Georgia; Chicago, Illinois; Dallas, Texas; Louisville, Kentucky; Minneapolis, Minnesota; Philadelphia, Pennsylvania; Salt Lake City, Utah. You will be fully remote; however, our approach to work may adapt over time. Future models could potentially involve a hybrid presence at the hub office associated with your metro area. #LI-Remote Pay Transparency: The base pay for this role is: $82,717 - $108,566 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program, and annual performance bonuses. 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 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 and 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 This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here. 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 and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives. Pay Transparency: Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements. Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts. Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications, without regard to applicant’s disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known. California Residents: For information about our collection, use, and disclosure of applicants’ personal information as well as applicants’ rights over their personal information, please see our Privacy Policy.