Senior Analyst, Payment Integrity Disputes

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

📋 Description

• Assist in resolving payment integrity disputes and issues within Oscar's claims environment.

• Define, assess, investigate, and implement solutions and process enhancements.

• Utilize expertise in claims infrastructure, workflows, workflow tools, platform logic, and data models.

• Collaborate across functions to convert stakeholder challenges into actionable improvement opportunities.

• Act as a subject matter expert on reimbursement policies, payment integrity disputes, claims processing edits, and vendor edits.

• Address inquiries and disputes from both internal and external sources.

• Investigate industry-standard coding regulations and contribute to the formulation of reimbursement policy language and scope.

• Generate payment integrity opportunities and convert them into business requirements.

• Work with internal partners to implement changes effectively.

• Analyze adverse claim outcomes, define and prioritize issues, and provide solutions.

• Identify common themes through partner submissions, data analysis, and process monitoring.

• Keep stakeholders updated on progress, changes in status, obstacles, and completions.

• Conduct research, perform root cause analysis, and deliver training for escalated issues.

• Adhere to relevant laws and regulations.

• Execute additional responsibilities as necessary.

⛳️ Requirements

• Experience in Payment Integrity with a focus on disputes and/or appeals.

• Over 4 years of experience in claims processing, coding, auditing, or healthcare operations.

• More than 3 years of experience in medical coding.

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

• Familiarity with reimbursement methodologies, provider contract concepts, and standard claims processing and resolution practices.

• At least 2 years of experience in deriving business insights from datasets and problem-solving.

• A minimum of 1 year of experience in enhancing business workflows and processes.

• Over 1 year of experience working collaboratively with internal and external stakeholders.

🏝️ Benefits

• Employee benefits.

• Unlimited vacation program.

• Annual performance bonuses.

• Medical benefits.

• Dental benefits.

• Vision benefits.

• 11 paid holidays.

• Paid sick time.

• Paid parental leave.

• Participation in a 401(k) plan.

• Life insurance.

• Disability insurance.

• Paid wellness time.

• Wellness reimbursements.