Associate, Payment Integrity

This is a fully remote position, open to applicants in Illinois, +5 more states.

📋 Description

• Conduct a thorough line-by-line analysis of high-value facility itemized bills and corresponding claim forms, such as UB-04s.

• Identify and document possible billing discrepancies, including duplicate billing, improper unbundling, and charges for services that are non-covered or non-rendered.

• Compare billed amounts against payor-specific contracts and industry standards.

• Utilize coding systems to ensure the accuracy of codes applied to billed services.

• Review claims based on specific reimbursement scenarios and minimum payor dollar thresholds.

• Document findings, savings identified, policy infractions, and suggested claim modifications.

• Enhance internal audit processes and tools.

• Act as a subject matter expert on intricate billing matters, coding standards, and payor regulations.

• Offer expertise on claims processing edits, vendor modifications, and Oscar reimbursement policies.

• Detect claims payment discrepancies through data analysis and process observation; outline necessary remediation actions.

• Address inquiries and disputes concerning policies and edits.

• Document coding guidelines and propose language and scope for reimbursement policies.

• Identify opportunities for payment integrity, convert them into business requirements, and collaborate with internal stakeholders.

• Provide training and educational support to team members.

• Keep stakeholders updated on progress, changes in status, obstacles, and completion of tasks.

• Assist with escalated issues through research, root cause analysis, and training.

• Adhere to all applicable laws and regulations.

• Carry out other duties as assigned.

⛳️ Requirements

• A bachelor's degree or 4+ years of equivalent experience.

• At least 2 years of experience in bill/coding audits, focusing on hospital or facility billing (UB-04).

• A minimum of 4 years of experience in medical coding.

• Medical coding certification from AAPC (CPC, COC) or AHIMA (CCS, RHIT, RHIA).

• Proficient in reimbursement methodologies, provider contract principles, and common practices in claims processing/resolution.

• Familiarity with national coding systems, including CPT, HCPCS, ICD-10, and MS-DRGs.

• Candidates must reside in Atlanta, Georgia; Chicago, Illinois; Dallas, Texas; Louisville, Kentucky; Minneapolis, Minnesota; Philadelphia, Pennsylvania; or Salt Lake City, Utah.

🏝️ Benefits

• Employee benefits.

• Oscar's unlimited vacation program.

• Annual performance bonuses.

• Medical benefits.

• Dental benefits.

• Vision benefits.

• 11 paid holidays.

• Paid sick leave.

• Paid parental leave.

• Participation in a 401(k) plan.

• Life insurance.

• Disability insurance.

• Paid wellness time and reimbursements.