Associate, Payment Integrity, IBR

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

Perform line-by-line review of high-dollar facility itemized bills and corresponding claim forms (UB-04s) Proactively identify and document potential billing errors, including duplicate billing, improper unbundling, and charges for non-covered services Compare billed charges against payor-specific contracts and industry guidelines Apply knowledge of national coding systems (CPT, HCPCS, ICD-10, MS-DRGs) to validate code accuracy Review claims eligible under specific reimbursement scenarios (percentage of charges or exceeding stop-loss levels) Prepare clear, concise documentation of findings, savings, policy violations, and recommended adjustments Contribute to the refinement of internal audit processes and tools Serve as a subject matter expert for internal and external stakeholders on billing issues, coding guidelines, and payor policies Provide subject matter expertise on internal claims processing edits, external vendor edits, and reimbursement policies Identify claims payment issues from data mining and process monitoring, providing scoping and remediation steps Respond to internal and external inquiries and disputes regarding policies and edits Document industry standard coding rules and provide recommendations on reimbursement policy language Ideate payment integrity opportunities based on coding rules and translate them into business requirements for collaboration with internal partners Provide training and education to team members Maintain a culture of transparency and collaboration by keeping stakeholders informed Support Oscar run state objectives by providing research, root cause analysis, and training for escalated issues Ensure compliance with all applicable laws and regulations