Associate, Payment Integrity

Oscar Health•New York City, NY

6d•Hybrid

About The Position

The Payment Policy Associate manages and executes all payment policy activities, including organizing, scoping, investigating, and resolving payment policy issues. Responsibilities also involve delegating and prioritizing project tasks effectively. This work relies on internal team research and a thorough understanding of Oscar's claim infrastructure to draft and update payment policies accurately. You will report into the Manager, Payment Integrity. 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 and events, while your other two office days are flexible to suit your schedule.

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 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

Responsibilities

Provide subject matter expertise and in-depth understanding of Payment Integrity internal claims processing edits, external vendor edits and Oscar reimbursement policies.
Analyze data mining and process monitoring to pinpoint claims payment issues, then define the scope and steps for policy remediation.
Examine industry standards to confirm claim payments align with industry best practices, internal policies, and regulations—both industry-wide and Oscar-specific.
Respond to internal and external inquiries and disputes regarding policies and edits.
Document industry standard coding rules and draft 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.
Attend regulation update meetings and relay information to team members, providing training and education as needed.
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