Associate, Payment Integrity Insurance Operations

Oscar Health Insurance; Mississippi; Remote; USD 79,000 - 105,000; Full time

Job summary

An innovative health insurance company is seeking an Associate for its Payment Integrity team. This role involves ensuring claims are processed accurately and timely by auditing existing policies and analyzing data. The ideal candidate will leverage their expertise in claims processing and medical coding, particularly in Anesthesia, to identify improvement opportunities. Join a forward-thinking team that values transparency and collaboration, where you can make a significant impact in the healthcare industry while enjoying a flexible work environment. This is a fantastic opportunity for those passionate about enhancing healthcare processes and delivering excellent service to members.

Benefits

Unlimited vacation program

Medical, dental, and vision benefits

401(k) plan participation

Paid parental leave

Life and disability insurance

Paid wellness time and reimbursements

11 paid holidays

Flexible work environment

Qualifications

• Bachelor's degree or 4+ years of relevant experience required.
• 4+ years in claims processing or healthcare operations preferred.

Responsibilities

• Support process improvement and issue resolution in claims processing.
• Analyze data and audit existing policies for accuracy.

Skills

Claims Processing

Medical Coding

Auditing

Data Analysis

Anesthesia Coding

Education

Bachelor's Degree

Medical Coding Certification

Tools

Excel

SQL

Job description

Hi, we're Oscar. We're hiring an Associate 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 process improvement and issue resolution in the Oscar claim environment for both the Oscar Insurance business and Payment Integrity vendors. The Associate, Payment Integrity is responsible for ensuring claims are paid accurately and timely by analyzing data and auditing existing policies and edits. This is accomplished by leveraging a deep understanding of Oscar’s claim infrastructure, payment policies, edit logic, vendor specifications, regulatory guidelines etc., to work cross-functionally to understand and identify opportunities for improvement. The Associate provides thought leadership for Payment Integrity process and workflows that impact claims edits and logic, and works closely with cross functional partners on execution of changes.

You will report to the Senior 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, Oscar reimbursement policies with a specialized focus on Anesthesia billing and coding.
• 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, edit logic, and creating and building exclusions.
• 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 experience in medical coding and deep understanding of Anesthesia coding guidelines
• 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

Bonus Points

• 3+ years of experience working with large data sets using excel or a database language
• Experience coaching and training team members
• 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

This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here .

At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives.

Pay Transparency: Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements.

Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications, without regard to applicant’s disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team ([e-mail]) to make the need for an accommodation known.

Artificial Intelligence (AI) Guidelines: Please see our AI Guidelines for the acceptable use of artificial intelligence during the interview process at Oscar.

California Residents: For information about our collection, use, and disclosure of applicants’ personal information as well as applicants’ rights over their personal information, please see our Notice to Job Applicants .

Hi, we're Oscar. We're hiring an Associate 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 process improvement and issue resolution in the Oscar claim environment for both the Oscar Insurance business and Payment Integrity vendors. The Associate, Payment Integrity is responsible for ensuring claims are paid accurately and timely by analyzing data and auditing existing policies and edits. This is accomplished by leveraging a deep understanding of Oscar’s claim infrastructure, payment policies, edit logic, vendor specifications, regulatory guidelines etc., to work cross-functionally to understand and identify opportunities for improvement. The Associate provides thought leadership for Payment Integrity process and workflows that impact claims edits and logic, and works closely with cross functional partners on execution of changes.

You will report to the Senior 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, Oscar reimbursement policies with a specialized focus on Anesthesia billing and coding.
• 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, edit logic, and creating and building exclusions.
• 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 experience in medical coding and deep understanding of Anesthesia coding guidelines
• 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

Bonus Points

• 3+ years of experience working with large data sets using excel or a database language
• Experience coaching and training team members
• 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

This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here .

At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives.

Pay Transparency: Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements.

Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications, without regard to applicant’s disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team ([e-mail]) to make the need for an accommodation known.

Artificial Intelligence (AI) Guidelines: Please see our AI Guidelines for the acceptable use of artificial intelligence during the interview process at Oscar.

California Residents: For information about our collection, use, and disclosure of applicants’ personal information as well as applicants’ rights over their personal information, please see our Notice to Job Applicants .