Associate, Payment Integrity, IBR

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

Perform line-by-line review of high-dollar facility itemized bills and corresponding claim forms Identify and document potential billing errors, including duplicate billing and improper unbundling Compare billed charges against payor-specific contracts and industry guidelines Apply working knowledge of national coding systems to validate accuracy of service codes Review claims eligible under specific reimbursement scenarios Prepare clear, concise, and professional documentation of findings Contribute to the refinement of internal audit processes and tools Serve as a subject matter expert for internal and external stakeholders Provide subject matter expertise on Payment Integrity internal claims processing edits, external vendor edits and reimbursement policies Identify claims payment issues from data mining and process monitoring Respond to internal and external inquiries and disputes Document industry standard coding rules and provide recommendations on reimbursement policy Ideate payment integrity opportunities based on coding rules and translate into business requirements Provide training and education to team members Perpetuate a culture of transparency and collaboration Support Oscar run state objectives Compliance with all applicable laws and regulations