Associate, Payment Integrity IBR

• Perform line-by-line review of high-dollar facility itemized bills and corresponding claim forms (e.g., UB-04s)
• Proactively identify and document potential billing errors, including duplicate billing of items, services, or procedures as improper unbundling of services (e.g., separating components that should be billed together) and charges for non-covered or non-rendered services
• Compare billed charges against both payor-specific contracts and industry guidelines to confirm appropriate billing practices.
• Apply working knowledge of national coding systems (e.g., CPT, HCPCS, ICD-10, MS-DRGs) to validate the accuracy of codes used for services billed.
• Review claims eligible under specific reimbursement scenarios: a percentage of charges or those exceeding stop-loss levels, ensuring the claim exceeds the minimum dollar threshold set by the payor
• Prepare clear, concise, and professional documentation of all findings, including savings identified, policy violations, and recommended claim adjustments
• Contribute to the refinement of internal audit processes and tools to enhance efficiency and accuracy in identifying claim inaccuracies
• Serve as a subject matter expert for internal and external stakeholders regarding complex billing issues, coding guidelines, and payor policies
• Provide subject matter expertise and in-depth understanding of Payment Integrity internal claims processing edits, external vendor edits and Oscar reimbursement policies
• Identify claims payment issues from data mining, process monitoring, etc., provide scoping and action steps needed to remediate the issue
• 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
• 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

• A bachelor's degree or 4+ years of commensurate experience
• 2+ years of bill / coding audit experience with a focus on hospital or facility billing (UB-04)
• 4+ years 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+ years of experience working with large data sets using excel or a database language
• Knowledge management, training, or content development in operational settings
• Process Improvement or Lean Six Sigma training
• Experience using SQL

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