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Salary: USD 82,717 - 108,566 / annual
Oscar Health is seeking an Associate for Payment Integrity focused on Itemized Bill Review (IBR). This role is part of the Payment Integrity team and reports to the Manager, Payment Integrity (Pre-Pay).
You will execute internal payment integrity solutions by performing detailed line-by-line reviews of high-dollar facility itemized bills and corresponding claim forms (UB-04s). Your core responsibilities include identifying and documenting potential billing errors such as duplicate billing, improper unbundling of services, and charges for non-covered or non-rendered services. You will compare billed charges against payor-specific contracts and industry guidelines, applying working knowledge of national coding systems (CPT, HCPCS, ICD-10, MS-DRGs) to validate billing accuracy.
You will review claims under specific reimbursement scenarios, prepare clear documentation of findings including identified savings and recommended adjustments, and contribute to refining internal audit processes and tools. The role requires serving as a subject matter expert for internal and external stakeholders on complex billing issues, coding guidelines, and payor policies. You will identify claims payment issues through data mining and process monitoring, provide scoping and remediation steps, and respond to inquiries and disputes regarding policies and edits.
Additionally, you will document industry standard coding rules, provide recommendations on reimbursement policy language, ideate payment integrity opportunities based on coding knowledge, provide training to team members, and support Oscar's operational objectives through research, root cause analysis, and escalated issue resolution.
The position is hybrid, based in Tempe, Arizona, requiring 3 days in-office per week with Thursdays mandatory for team meetings and events.
