Senior Analyst, Payment Integrity

Oscar Health•New York City, NY

7h•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 Senior Analyst, Payment Integrity role organizes, scopes, prepares, investigates and/or executes on solutions and process improvements within edits and ideation. 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.

Requirements

A bachelor’s degree or 4+ years of commensurate experience
3+ years of experience in claims processing, coding, auditing or health care claims operations
3+ years experience in medical coding within payment integrity
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/or 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)
Process Improvement or Lean Six Sigma training
Experience using SQL

Responsibilities

Contribute as a subject matter expert for Oscar reimbursement policies, payment integrity 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 issues are escalated and assigned by leadership.
Compliance with all applicable laws and regulations
Other duties as assigned