SIU Coding Auditor

About Oscar Health

Hi, we're Oscar. We're hiring an SIU Coding Auditor to join our SIU.

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 ourselves—one that behaves like a doctor in the family.

About The Role: SIU Coding Auditor

The SIU Coding Auditor executes on Oscar's anti-fraud initiatives by supporting operational and financial targets while adhering to legal and regulatory obligations. You will help execute on audit strategy by ensuring team productivity is met while ensuring quality remains high. The auditor networks across all partners, and recommends enhancements to processes, policies, and procedures to support a best in class Fraud Waste and Abuse program. We ask that you have attention to detail, innovation, and ability to shift priorities to align with operational needs.

You will report into the Manager, SIU Coding Audit.

Work Location: This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; or Texas. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events.

Pay Transparency: The base pay for this role is: $75,265 - $98,785 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program and annual performance bonuses.

Responsibilities

• Perform quality checks of other team members' coding audit reviews and deliver in written or verbal form to ensure accuracy and compliance with coding standards and Oscar policy.
• Review dashboards and interpret performance data in support of production goals; Recommend response and inform management before deadlines are missed.
• Identify and help develop new processes to ensure efficient and effective audit functions.
• Perform complex reviews of medical records and claims on both a prepayment and post payment basis to determine accuracy of claims submitted to Oscar.
• Explicitly document findings including sources used to support decision making and in a way that can be easily understood by non clinicians or coders.
• Participate in educational calls or written communications to articulate findings to providers under SIU review.
• Facilitate team and cross-team education
• Compliance with all applicable laws and regulations
• Other duties as assigned

Requirements

• Bachelor's degree or equivalent years of experience
• Certified Professional Coder (CPC) designation or similar
• 3+ years of coding or auditing experience across multiple specialties.

Bonus Points

• Certified Professional Medical Auditor
• Additional certification applicable to this work such as Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML [Anti-Money Laundering] and Fraud Professional (CAFP), other coding certifications or similar
• Knowledge of applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity
• Experience working in health insurance specifically with claims processing, billing, reimbursement, or provider contracting.
• Experience with HIPAA, data privacy, and/or data security processes
• Experience working with regulators governing (public or private) health insurance carriers

Key skills/competency

• Medical Coding
• Claims Auditing
• Fraud Detection
• Compliance
• FWA (Fraud, Waste, and Abuse)
• Regulatory Adherence
• Documentation
• Process Improvement
• Quality Assurance
• Risk Management