Payment Integrity Specialist — Claims & Data Insights

Oscar Health; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

Oscar Health seeks a claims analytics professional to support process improvement and issue resolution in the Oscar claim environment for Oscar Insurance and +Oscar clients. You will translate stakeholder friction into actionable opportunities using deep knowledge of claim infrastructure, workflows, and data models.

You will provide SME on Payment Integrity edits, respond to inquiries, document coding rules, and collaborate with partners to scope improvements, deriving insights to guide policy

Qualifications

• Bachelor's degree or 4+ years commensurate experience, plus 4+ years in claims processing, coding, or healthcare operations.
• Medical coding certification through AAPC or AHIMA and experience with reimbursement methodologies.
• 2+ years deriving business insights from datasets and 1+ years improving workflows and collaborating with stakeholders.

Responsibilities

• Provide subject matter expertise on Payment Integrity edits, vendor edits, and reimbursement policies.
• Respond to inquiries and disputes, document coding rules, and recommend policy and scope changes.
• Collaborate with partners to scope and deliver improvements, and use data insights to identify thematic areas of opportunity.

Skills

Payment integrity edits

Vendor edits

Reimbursement policies

Stakeholder collaboration

Data insights

Education

Bachelor's degree or equivalent experience

Job description

Oscar Health seeks a claims analytics professional to support process improvement and issue resolution in the Oscar claim environment for Oscar Insurance and +Oscar clients. You will translate stakeholder friction into actionable opportunities using deep knowledge of claim infrastructure, workflows, and data models.

You will provide SME on Payment Integrity edits, respond to inquiries, document coding rules, and collaborate with partners to scope improvements, deriving insights to guide policy