Claims Quality Control Sr. Analyst

Hi, we're Oscar. We're hiring a Claims Quality Control Sr. Analyst to join our  Claims Lifecycle team.

Oscar is the first health insurance company built around a full stack technology platform and a 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

As a Claims Quality Control (QC) Sr. Analyst, you will be responsible for the end to end claims quality review process and conducting root cause analysis for errors found in monthly claims audits and quality initiatives. You will work in conjunction with the Claims QC Analyst as well as other internal Oscar teams ranging from Operations, Control Operations, finance and technical teams.

You will report to the Director of Payment Integrity.

This is a remote / work-from-home role. You must reside in one of the following states: Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Iowa, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change. #LI-Remote

The base pay for this role in the states of California, Connecticut, New Jersey, New York, and Washington is: $76,000 - $99,750 per year. The base pay for this role in all other locations is: $68,400 - $89,775 per year. You are also eligible for employee benefits, and annual performance bonuses.

Responsibilities

• Develop an in-depth understanding of Claims processing workflows
• Coordinate with other teams to finalize evidence for claims QC process
• Provide guidance to team members on pricing methodology, cost share, accumulators, denials, benefit, authorization application, logic against internal and external sources of truth including State and Federal Guidelines. 
• Review and approve supporting documentation for each claim that allows internal and external parties to easily conclude the accuracy of an individual claim payment . 
• Become a SME of Cortex, Nucleus, Rosco and other internal and external tools to complete audits and provide guidance to team members 
• Ensure impact analysis and  root cause analysis is completed monthly 
• Become well-acquainted with internal tools and technical processes, and highlight areas of opportunity for improvement
• Become an in-house expert on data structure and visualization for various stakeholders in service operations
• Responsible for peer review of others on the team
• Mediates errors with key stakeholders

Qualifications

• Bachelor’s degree or 4+ years of experience in claims processing, auditing or health care operations
• 1+ year(s) ability to work independently to drive projects to completion
• 2+ years of experience in healthcare claims processing, benefit or provider configuration

Bonus Points

• Bachelor’s degree 
• Some coding experience or database language exposure
• 2+ years of related work experience in analytics or operations

This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here. 

At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives..

Pay Transparency: 

Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience.

Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements.

Reasonable Accommodation:

Oscar applicants are considered solely based on their qualifications, without regard to applicant’s disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known.