Payment Integrity Associate - Itemized Bill Review

📋 Description

• • Join Oscar Health, a pioneering health insurance company revolutionizing the industry with its innovative technology platform and member-centric approach, as an Associate, Itemized Bill Review within our dynamic Payment Integrity team.
• • In this critical role, you will be instrumental in executing and continuously improving our internal payment integrity solutions, leveraging your specialized knowledge of medical billing and coding to ensure claims are processed with the utmost accuracy, timeliness, and quality.
• • You will gain a deep understanding of Oscar's sophisticated claim infrastructure, including workflows, platform logic, and data models, enabling you to collaborate effectively across departments.
• • Your primary responsibility will be to translate stakeholder feedback and identified friction points into actionable opportunities for process enhancement and solution development.
• • This position offers the unique opportunity to work remotely, contributing to Oscar's mission from your home base while potentially engaging with a local hub office in the future.
• • You will report directly to the Manager, Payment Integrity (Pre-Pay), a key leader in safeguarding the financial integrity of our operations.
• • Perform meticulous line-by-line reviews of high-dollar facility itemized bills, thoroughly examining associated claim forms such as UB-04s to detect any discrepancies or potential overpayments.
• • Proactively identify and meticulously document a wide range of billing errors, including but not limited to, duplicate billing of services or items, improper unbundling of procedures that should be billed together, and charges for services that were not rendered or are not covered under the member's plan.
• • Critically compare billed charges against established payor-specific contracts and recognized industry guidelines to rigorously confirm that all billing practices adhere to appropriate standards and contractual obligations.
• • Apply your comprehensive working knowledge of national coding systems, including CPT, HCPCS, ICD-10, and MS-DRGs, to validate the accuracy and appropriateness of the codes submitted for all billed services.
• • Conduct in-depth reviews of claims that fall under specific reimbursement scenarios, such as those billed as a percentage of charges or claims that exceed defined stop-loss thresholds, ensuring that the claim meets or exceeds the minimum dollar threshold established by the payor.
• • Prepare clear, concise, and professional documentation detailing all findings from your reviews. This documentation will include the quantification of identified savings, evidence of policy violations, and specific, actionable recommendations for claim adjustments.
• • Actively contribute to the ongoing refinement and enhancement of our internal audit processes and the tools we utilize, aiming to boost both the efficiency and the accuracy of our claim inaccuracy identification efforts.
• • Serve as a go-to subject matter expert for both internal teams and external partners, providing insightful guidance on complex billing issues, intricate coding guidelines, and nuanced payor policies.
• • Offer specialized subject matter expertise and a profound understanding of Oscar's internal claims processing edits, the edits applied by our external vendors, and Oscar's specific reimbursement policies.
• • Proactively identify claims payment issues through diligent data mining, continuous process monitoring, and other analytical methods. You will be responsible for scoping these issues and defining the necessary remediation steps.
• • Respond promptly and professionally to all internal and external inquiries and disputes related to our policies and claim processing edits.
• • Document and maintain up-to-date knowledge of industry-standard coding rules and regulations, and leverage this expertise to provide informed recommendations on the language and scope of our reimbursement policies.
• • Generate innovative payment integrity opportunities by drawing upon your deep understanding of industry-standard coding rules. You will translate these opportunities into detailed business requirements and collaborate with internal partners to implement necessary changes.
• • Provide essential training and educational support to fellow team members as needed, fostering a knowledgeable and skilled team environment.
• • Champion a culture of transparency and collaboration by consistently keeping stakeholders informed about the progress, status changes, identified blockers, and completion of your work. You will be expected to field questions effectively and maintain open lines of communication.
• • Support Oscar's overarching strategic objectives by providing rapid research, thorough root cause analysis, and targeted training whenever issues are escalated and assigned by leadership.
• • Ensure strict compliance with all applicable laws and regulations governing healthcare billing and payment integrity.
• • Undertake other duties as assigned, demonstrating flexibility and a commitment to the team's success.