Utilization review nurse [h1.location_city]

Associate, Itemized Bill Review

Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselvesone that behaves like a doctor in the family.

The Associate, Payment Integrity, Itemized Bill Review (IBR) will be responsible for executing internal payment integrity solutions requiring billing and coding expertise with and continual improvement and development of the solutions. You will ensure claims are paid accurately and timely with the highest quality. This is accomplished by leveraging a deep understanding of Oscar's claim infrastructure, workflows, workflow tooling, platform logic, data models, etc., to work cross-functionally to understand and translate friction from stakeholders into actionable opportunities for improvement.

You will report into the Manager, Payment Integrity (Pre-Pay).

This is a remote position, open to candidates who reside in : Atlanta, Georgia; Chicago, Illinois; Dallas, Texas; Louisville, Kentucky; Minneapolis, Minnesota; Philadelphia, Pennsylvania; Salt Lake City, Utah. You will be fully remote; however, our approach to work may adapt over time. Future models could potentially involve a hybrid presence at the hub office associated with your metro area.

The base pay for this role is : $82,717 - $108,566 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program, and annual performance bonuses.

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 of items, services, or procedures as improper unbundling of services (e.g., separating components that should be billed together) and charges for non-covered or non-rendered services
• Compare billed charges against both 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 : 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., 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 a deep knowledge of industry standard coding rules. Translate into business requirements; submit to 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 well informed of progress, status changes, blockers, completion, etc.; 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
• Compliance with all applicable laws and regulations
• Other duties as assigned

Requirements

Bonus Points