Associate, Payment Integrity IBR

Oscar is the first health insurance company built around a full-stack technology platform and a relentless focus on serving our members. Founded in 2012, we aim 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 Associate, Payment Integrity, Itemized Bill Review (IBR) will execute internal payment integrity solutions requiring billing and coding expertise, while continually improving and developing these solutions. You will ensure claims are paid accurately and timely with the highest quality by leveraging a deep understanding of Oscar's claim infrastructure, workflows, tooling, platform logic, and data models. This role involves cross-functional collaboration to translate stakeholder friction into actionable improvements. You will report to the Manager, Payment Integrity (Pre-Pay).

This position is based in our Tempe, Arizona office, requiring a hybrid work schedule with 3 days of in-office work per week. Thursdays are a required in-office day for team meetings and events, while your other two office days are flexible.

Responsibilities

• Perform line-by-line review of high-dollar facility itemized bills and corresponding claim forms (e.g., UB-04s).
• Proactively identify and document potential billing errors, including duplicate billing, improper unbundling of services, and charges for non-covered or non-rendered services.
• Compare billed charges against payor-specific contracts and industry guidelines to confirm appropriate billing practices.
• Apply working knowledge of national coding systems (e.g., CPT, HCPCS, ICD-10, MS-DRGs) to validate the accuracy of codes used for services billed.
• Review claims eligible under specific reimbursement scenarios, such as a percentage of charges or those exceeding stop-loss levels, ensuring the claim exceeds the minimum dollar threshold set by the payor.
• Prepare clear, concise, and professional documentation of all findings, including savings identified, policy violations, and recommended claim adjustments.
• Contribute to the refinement of internal audit processes and tools to enhance efficiency and accuracy in identifying claim inaccuracies.
• Serve as a subject matter expert for internal and external stakeholders regarding complex billing issues, coding guidelines, and payor policies.
• Provide subject matter expertise and in-depth understanding of Payment Integrity internal claims processing edits, external vendor edits, and Oscar reimbursement policies.
• Identify claims payment issues from data mining, process monitoring, etc., and 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 language and scope.
• Ideate payment integrity opportunities based on deep knowledge of industry-standard coding rules, translate into business requirements, 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 informed of progress, status changes, blockers, and completion; 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.
• Ensure compliance with all applicable laws and regulations.
• Perform other duties as assigned.

Requirements

• A bachelor's degree or 4+ years of commensurate experience.
• 2+ years of bill/coding audit experience with a focus on hospital or facility billing (UB-04).
• 4+ years of experience in medical coding.
• 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.

Bonus Points

• 3+ years of experience working with large data sets using Excel or a database language.
• Knowledge management, training, or content development in operational settings.
• Process Improvement or Lean Six Sigma training.
• Experience using SQL.

Pay

The base pay for this role is $82,717 - $108,566 per year.

Benefits

• Medical, dental, and vision benefits.
• 11 paid holidays.
• Paid sick time.
• Paid parental leave.
• 401(k) plan participation.
• Life and disability insurance.
• Paid wellness time and reimbursements.
• Unlimited vacation program.
• Annual performance bonuses.