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Salary: USD 82,717 - 120,629 / annual
Oscar Health is seeking an Associate, Itemized Bill Reviewer to join the Payment Integrity team. This role focuses on executing internal payment integrity solutions with expertise in billing and coding, ensuring claims are paid accurately and timely while driving continuous improvement.
You will perform line-by-line reviews of high-dollar facility itemized bills and corresponding claim forms (UB-04s), proactively identifying and documenting potential billing errors including 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.
Key responsibilities include preparing clear documentation of findings and recommended claim adjustments, contributing to refinement of internal audit processes and tools, and serving as a subject matter expert for internal and external stakeholders on complex billing issues and coding guidelines. You will identify claims payment issues through data mining and process monitoring, provide scoping and remediation steps, respond to inquiries and disputes regarding policies and edits, and document industry standard coding rules with recommendations on reimbursement policy language.
Additionally, you will ideate payment integrity opportunities based on deep knowledge of coding rules, translate these into business requirements, collaborate with internal partners to effectuate change, provide training to team members, maintain stakeholder communication on progress and blockers, and support Oscar run-state objectives through research and root cause analysis.
Reporting to the Manager, Payment Integrity (Pre-Pay), this is a fully remote position open to US candidates (excluding Alaska, Delaware, Hawaii, Louisiana, Montana, North Dakota, Oklahoma, West Virginia, Wyoming, and US Territories). Occasional travel may be required for team meetings and company events.
**Requirements:**
- Bachelor's degree or 4+ years of commensurate experience
- 2+ years of bill/coding audit experience with focus on hospital or facility billing (UB-04)
- 4+ years of medical coding experience
- 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
**Bonus qualifications:**
- 3+ years of experience working with large data sets using Excel or database language
- Knowledge management, training, or content development in operational settings
- Process Improvement or Lean Six Sigma training
- SQL experience
