Medical Coding Auditor, SIU

Oscar Health; United States; Hybrid; USD 56,880 - 82,950; Full time

Benefits offered by this job

Unlimited vacation program

Annual performance bonuses

Employee benefits

Job summary

An innovative health insurance company is seeking a detail-oriented Medical Coding Auditor to join their Special Investigations Unit (SIU). In this role, you will leverage your coding expertise to assess trends in fraud, waste, and abuse within the healthcare industry. You will be responsible for auditing claims, documenting findings, and developing processes to enhance team effectiveness. This position offers a unique opportunity to work in a blended culture, combining remote flexibility with in-office collaboration. Join a forward-thinking organization that prioritizes member care and embraces a mission-driven approach to health insurance.

Qualifications

• 1+ years of coding or auditing experience across multiple specialties.
• Bachelor’s degree or equivalent work experience required.

Responsibilities

• Audit medical records and claims for accuracy and compliance.
• Create reports and guides for team members to communicate findings.
• Train new team members and improve team processes.

Skills

CPT Coding

ICD-10 Coding

HCPCS Coding

Auditing

Medical Billing

Fraud Detection

Communication Skills

Education

Bachelor's Degree

4+ years of work experience

Tools

Medical Coding Software

Job description

Hi, we're Oscar. We're hiring a Medical Coding Auditor, SIU, to join our SIU 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

The Senior Specialist, Medical Coding Auditor, SIU, works to support in assessing trends and patterns in FWA across the healthcare industry using deep coding knowledge to audit prepayment and/or post payment claims. The Senior Specialist runs and coordinates activities across Oscar to reduce the incidence and effect of fraud, waste, and/or abuse (“FWA”) on all our operations.

You will report to the Associate Director, SIU.

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, California, Colorado, Connecticut, Florida, Georgia, Illinois, 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: $63,200 - $82,950 per year. The base pay for this role in all other locations is: $56,880 - $74,655 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program and annual performance bonuses.

Responsibilities

• Develops and maintains a depth of expertise on CPT, HCPCS, and ICD-10 Coding guidelines and other insurance billing submission requirements.
• Perform complex policy updates or audits of assigned documentation (i.e. medical records or claims) on both a prepayment and/or post payment basis to determine accuracy of claims submitted to Oscar.
• Document findings including reference to sources used to support decision making and in a way that can be easily understood by non clinicians or coders.
• Create reports and reference guides that can be used by other team members to communicate findings or more effectively perform similar reviews.
• Help draft written communications to providers to convey findings.
• Participate in educational calls with providers.
• Help train new team members.
• Develop and document processes to improve the effectiveness of the team.
• Compliance with all applicable laws and regulations.
• Other duties as assigned.

Qualifications

• 1+ years of coding or auditing experience across multiple specialties.
• Bachelor’s degree or 4+ years of work experience.

Bonus Points

• Certified Professional Coder (CPC) designation or similar certification (required for SIU).
• Certified Professional Medical Auditor.
• Additional certification applicable to this work such as Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML [Anti-Money Laundering] and Fraud Professional (CAFP), other coding certifications or similar.
• Knowledge of applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity.
• Demonstrated experience translating technical jargon to non-technical end users.
• Experience working in health insurance specifically with claims processing, billing, reimbursement, or provider contracting.
• Experience with HIPAA, data privacy, and/or data security processes.
• Experience working with regulators governing (public or private) health insurance carriers.