Associate, Payment Integrity Disputes

Hi, we're Oscar. We're hiring an Associate, Payment Integrity Disputes to join our Payment Integrity team.

Oscar is the first health insurance company built around a full stack technology platform and a focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family.

About the role

This role is responsible for supporting disputes process improvement and issue resolution in the Oscar payment integrity environment for the Oscar Insurance business. The Associate, Payment Integrity Disputes is responsible for ensuring disputes are reviewed and resolved accurately and timely. This is accomplished by leveraging a deep understanding of Oscar’s claim infrastructure, workflows, workflow tooling, platform logic, etc., to work cross-functionally to understand and translate friction from stakeholders into actionable opportunities for improvement. The Associate provides thought leadership for Payment Integrity process and workflows that impact claims payments and works closely with cross functional partners on execution of changes.

You will report to the Manager, Payment Integrity.

Work Location: 

Oscar is a blended work culture where everyone, regardless of work type or location, feels connected to their teammates, our culture and our mission. 

If you live within commutable distance to our New York City office (in Hudson Square), our Tempe office (off the 101 at University Dr), or our Los Angeles office (in Marina Del Rey), you will be expected to come into the office at least two days each week. Otherwise, this is a remote / work-from-home role.  

You must reside in one of the following states: Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change. #LI-Remote

Pay Transparency:

The base pay for this role in the states of California, Connecticut, New Jersey, New York, and Washington is: $88,800 - $116,550 per year. The base pay for this role in all other locations is: $79,920 - $104,895 per year. You are also eligible for employee benefits, participation in Oscar’s unlimited vacation program and annual performance bonuses.

Responsibilities

• Provide subject matter expertise and in-depth understanding of Payment Integrity internal claims processing edits, external vendor edits and Oscar reimbursement policies.
• Identify payment integrity dispute issues from data mining, process monitoring, etc., provide scoping and action steps needed to remediate the issue.
• Conduct in depth medical record reviews and respond to internal inquiries and disputes regarding policies and edits.
• Apply industry standard coding rules to dispute review 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.
• Provide training and education to team members when necessary.
• 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

Qualifications

• 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 of experience in medical coding
• 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.
• 3+ year(s) ability to work independently to drive projects to completion
• 3+ years of experience working with large data sets using excel or a database language

Bonus Points

• Experience in a professional healthcare claims organization
• Knowledge management, training, or content development in operational settings
• Process Improvement or Lean Six Sigma training
• Experience using SQL