Oscar Health - Associate, Payment Integrity
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 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 • 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 • This is an authentic Oscar Health job opportunity.
Responsibilities
• Provide subject matter expertise and in-depth understanding of Payment Integrity internal claims processing edits, external vendor edits and Oscar reimbursement policies. • Respond to internal and external inquiries and disputes regarding policies and edits. • Document industry standard coding rules and provide 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. • 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
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