Associate, Payment Integrity

Oscar Health•Tempe, AZ

1h•Hybrid

About The Position

This role is responsible for supporting process improvement and issue resolution in the Oscar claim environment for both the Oscar Insurance business and +Oscar clients. The Associate, Payment Integrity is responsible for ensuring 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. The Associate provides thought leadership for Payment Integrity process and workflows that impact claims payments and works closely with cross functional partners on execution of changes. You will report into the Sr. Manager, Payment Integrity. Work Location: This position is based in our Tempe, Arizona 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 and events, while your other two office days are flexible to suit your schedule. #LI-Hybrid

Requirements

A bachelor's degree or 4+ years of commensurate experience
4+ years of experience in claims processing, coding, auditing or health care operations
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+ year(s) ability to work independently to drive projects to completion

Nice To Haves

3+ years experience in a technical role (QA analyst, PM, operations analyst, finance, consulting, industrial engineering) or a process improvement role (Six Sigma or similar)
3+ 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

Responsibilities

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