Senior Specialist, Coding Auditor

Oscar Health Insurance•New York, NY

55d•$56,880 - $82,950•Hybrid

About The Position

Oscar is the first health insurance company built around a full stack technology platform and a 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 Senior Specialist works in the Special Investigation Unit to support in assessing trends and patterns in FWA across the healthcare industry using deep coding knowledge to prevent and recoup inappropriately paid claims. The Specialist Investigation Unit runs and coordinates activities across Oscar to reduce the incidence and impact of fraud, waste, and/or abuse ("FWA") on all our operations. You will report to the Manager, SIU Coding Audit. Work Location: Oscar is a blended work culture where everyone, regardless of work type or location, feels connected to their teammates, our culture and our mission. If you live within commutable distance to our New York City office (in Hudson Square), our Tempe office (off the 101 at University Dr), or our Los Angeles office (in Marina Del Rey), you will be expected to come into the office at least two days each week. Otherwise, this is a remote / work-from-home role. You must reside in one of the following states: Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change. #LI-Remote

Requirements

2+ years of coding or auditing experience across multiple specialties is required
Bachelor's degree or 4+ years of work experience
Certified Professional Coder (CPC), Certified Inpatient Coder (CIC), Certified Outpatient Coder (COC) designation or similar certification
Experience working in production-based environment
Experience of both outpatient and inpatient auditing

Nice To Haves

Certified Professional Medical Auditor (CPMA)
Additional certification applicable to this work such as Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML [Anti-Money Laundering] and Fraud Professional (CAFP), other coding certifications or similar
Knowledge of applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity
Demonstrated experience translating technical jargon to non-technical end users.
Experience working in health insurance specifically with claims processing, billing, reimbursement, or provider contracting.
Experience with HIPAA, data privacy, and/or data security processes
Experience working with regulators governing (public or private) health insurance carriers

Responsibilities

Develop a depth of expertise on CPT, HCPCS, and ICD-10 Coding guidelines and other insurance billing submission requirements.
Perform complex audits of assigned medical records and claims on both a prepayment and post payment basis to determine accuracy of claims submitted to Oscar.
Document findings including reference to sources used to support decision making and in a way that can be easily understood by non clinicians or coders.
Create audit report findings, tools, and reference guide that can be used by other team members to communicate findings or more effectively perform similar reviews.
Help draft written communications to providers to convey audit findings.
Participate in educational calls with providers.
Help train new team members.
Develop and document processes to improve the effectiveness of the team.
Compliance with all applicable laws and regulations
Other duties as assigned