Payment Integrity Associate: Claims & Process Improvement

Oscar Health; Yuma (AZ); Remote; USD 83,000 - 109,000; Full time

Benefits offered by this job

Unlimited vacation

Annual bonus

Benefits package

Job summary

Oscar Health is seeking an Associate, Payment Integrity to help optimize claims processing and reimbursement policies in a remote role. You will analyze edits, respond to inquiries, and translate coding rules into actionable improvements across Oscar's claim environment.

The role requires strong experience in payment integrity, data-driven problem solving, and cross-functional collaboration. A bachelor’s degree or equivalent experience is expected with opportunities for growth and bonuses.

Qualifications

• 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 within payment integrity.
• 2+ years experience deriving business insights from datasets and solving problems.
• 1+ years experience improving business workflows and processes.
• 1+ years experience collaborating with internal and/or external stakeholders.

Responsibilities

• Provide subject matter expertise and in-depth understanding of Payment Integrity internal claims processing edits, external vendor edits and Oscar reimbursement policies.
• 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.
• Ingest information from internal and external partners regarding adverse claim outcomes; collaborate with partners to scope, size, prioritize items and deliver solutions.
• Use insights from partner submissions, data mining, process monitoring, etc., work with the team to proactively identify thematic areas of opportunity to solve problems.
• 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

Skills

Claims processing

Medical coding

Data analysis

Workflow improvement

Stakeholder collaboration

Education

Bachelor's degree

Tools

SQL

Job description

Oscar Health is seeking an Associate, Payment Integrity to help optimize claims processing and reimbursement policies in a remote role. You will analyze edits, respond to inquiries, and translate coding rules into actionable improvements across Oscar's claim environment.

The role requires strong experience in payment integrity, data-driven problem solving, and cross-functional collaboration. A bachelor’s degree or equivalent experience is expected with opportunities for growth and bonuses.