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Salary: USD 82,717 - 108,566 / annual
Oscar Health is seeking an Associate, Payment Integrity, Itemized Bill Review (IBR) to join its Payment Integrity team. This role focuses on executing internal payment integrity solutions with expertise in medical billing and coding. You will report to the Manager, Payment Integrity (Pre-Pay).
Key responsibilities include performing line-by-line reviews of high-dollar facility itemized bills and corresponding claim forms (UB-04s), identifying potential billing errors such as duplicate billing, improper unbundling, and charges for non-covered or non-rendered services. You will compare billed charges against payor-specific contracts and industry guidelines, apply knowledge of national coding systems (CPT, HCPCS, ICD-10, MS-DRGs) to validate billing accuracy, and review claims under specific reimbursement scenarios.
You will prepare detailed documentation of findings, including identified savings, policy violations, and recommended claim adjustments. The role requires contributing to refinement of internal audit processes and tools, serving as a subject matter expert for internal and external stakeholders on complex billing and coding issues, and identifying claims payment issues through data mining and process monitoring. You will respond to inquiries and disputes regarding policies and edits, document industry standard coding rules, and ideate payment integrity opportunities based on deep knowledge of coding standards.
Additional responsibilities include providing training to team members, maintaining transparency and collaboration with stakeholders, supporting run-state objectives through research and root cause analysis, and ensuring compliance with applicable laws and regulations.
Requirements: Bachelor's degree or 4+ years commensurate experience; 2+ years bill/coding audit experience focused on hospital or facility billing (UB-04); 4+ years medical coding experience; medical coding certification (AAPC: CPC/COC or AHIMA: CCS/RHIT/RHIA); experience with reimbursement methodologies, provider contracts, and claims processing. Bonus qualifications include 3+ years working with large datasets using Excel or database languages, knowledge management/training experience, Process Improvement or Lean Six Sigma training, and SQL experience.
