Payment Integrity Associate - Itemized Bill Review

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. 3+ years of experience working with large data sets using Excel or a database language (Bonus). Knowledge management, training, or content development (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 (UB-04). 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. Prepare clear and concise documentation of findings. Contribute to refining internal audit processes and tools. Serve as a subject matter expert for billing issues, coding guidelines, and payor policies. Provide expertise on 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 and translate them into business requirements. Provide training and education to team members. Maintain transparency and collaboration with stakeholders. Support Oscar run state objectives through research and root cause analysis. Comply with all applicable laws and regulations.