SIU Coding Auditor

Oscar Health•Tempe, AZ

1d•$75,265 - $98,785•Remote

About The Position

The Associate, Special Investigations Unit Coding Auditor executes on Oscar's anti-fraud initiatives by supporting operational and financial targets while adhering to legal and regulatory obligations. You will help execute on audit strategy by ensuring team productivity is met while ensuring quality remains high. The associate networks across all partners, and recommends enhancements to processes, policies, and procedures to support a best in class Fraud Waste and Abuse program. We ask that you have attention to detail, innovation, and ability to shift priorities to align with operational needs.

Requirements

Bachelor's degree or equivalent years of experience
Certified Professional Coder (CPC) designation or similar
3+ years of coding or auditing experience across multiple specialties.

Nice To Haves

Certified Professional Medical Auditor
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
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

Perform quality checks of other team members' coding audit reviews and deliver in written or verbal form to ensure accuracy and compliance with coding standards and Oscar policy.
Review dashboards and interpret performance data in support of production goals; Recommend response and inform management before deadlines are missed.
Identify and help develop new processes to ensure efficient and effective audit functions.
Perform complex reviews of medical records and claims on both a prepayment and post payment basis to determine accuracy of claims submitted to Oscar.
Explicitly document findings including sources used to support decision making and in a way that can be easily understood by non clinicians or coders.
Participate in educational calls or written communications to articulate findings to providers under SIU review.
Facilitate team and cross-team education
Compliance with all applicable laws and regulations
Other duties as assigned