Senior Analyst, Payment Integrity Disputes

Oscar Health•Tempe, AZ

6d•Hybrid

About The Position

You will be responsible for supporting payment integrity disputes and issue resolution in the Oscar claim environment for both the Oscar Insurance business. You will scope, triage, investigate and execute on solutions and process improvements. You will leverage a deep understanding of Oscar's claim infrastructure, workflows, workflow tooling, platform logic, data models, etc., to work cross-functionally and understand and translate friction from stakeholders into actionable opportunities for improvement. You will report into the Manager, Payment Integrity (Pre-Pay).

Requirements

Experience in Payment Integrity focused on Disputes and/or appeals
4+ years of experience in claims processing, coding, auditing or health care operations
3+ 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.
2+ years experience deriving business insights from datasets and solving problems
1+ years experience improving business workflows and processes
1+ years experience collaborating with internal and external stakeholders

Nice To Haves

2+ years experience in a technical role (QA analyst, PM, operations analyst, finance, consulting, industrial engineering) or a process improvement role (Six Sigma or similar)
2+ 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

Contribute as a subject matter expert for Oscar reimbursement policies, payment integrity disputes, internal claims processing edits and external vendor edits.
Respond to internal and external inquiries and disputes regarding policies and edits.
Research industry standard coding rules, summarize and provide input into reimbursement policy language and scope.
Use knowledge gained through research and claims review to ideate payment integrity opportunities. Translate into business requirements; submit to and collaborate with internal partners to effectuate change.
Ingest information from internal and external partners regarding adverse claim outcomes; collaborate with partners to scope, size, prioritize items and deliver solutions.
Use insights from partner submissions, data mining, process monitoring, etc., work with the team to proactively identify thematic areas of opportunity to solve problems.
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 leadership escalates and assigns issues.
Compliance with all applicable laws and regulations
Other duties as assigned