Associate Director, Appeals & Grievances

Oscar-Health-; Los Angeles (CA); Remote; USD 111,000 - 162,000; Full time

Benefits offered by this job

Unlimited vacation

Benefits package

Job summary

Oscar Health is hiring an Associate Director, Appeals & Grievances to oversee non-clinical CGA operations and the Elite Member Champion Team. The role focuses on regulatory compliance, process optimization, and cross-functional collaboration with Claims, Network, Legal and Compliance.

You will lead a high-performing team across remote locations, ensuring timely resolutions and system-wide improvements while advancing a strong talent pipeline through coaching and structured management.

Qualifications

• 7+ years in healthcare operations focusing on compliance, complaints, grievances, or appeals (A&G).
• 4+ years of people management in a high-volume operations setting.
• Advanced knowledge of Commercial Insurance, Medicare/Medicaid, ACA rules for administrative CGA processes.
• Experience leading audits with CMS, state regulators, or similar bodies.
• Experience using data to lead decisions, manage capacity, and drive process improvements.
• Bachelor's degree or equivalent experience required.
• Lean Six Sigma certification or equivalent is preferred.
• Experience leading remote or multi-site teams.

Responsibilities

• Lead CGA and Escalation teams, ensuring compliance and quality across lines of business.
• Build and coach a multi-tier management and specialist team with clear accountability.
• Serve as the final authority for high-visibility administrative complaints from leadership and regulators.
• Standardize evaluation, escalation, and resolution workflows to enable end-to-end case ownership.
• Maintain audit readiness and lead CMS and state regulatory audits.
• Partner with Claims, Network, Legal, and Compliance to drive systemic root-cause solutions.
• Use workforce data and Lean methods to improve efficiency and cost-effectiveness.
• Oversee delegated vendors to meet contractual and regulatory CGA standards.
• Present performance metrics and strategic recommendations to executives.
• Ensure adherence to all applicable laws and regulations.

Skills

Leadership

Strategic thinking

Data-driven decisions

Remote team leadership

Regulatory awareness

Education

Bachelor's Degree or equivalent

MBA/MHA/JD

Tools

Tableau

Looker

Jira

Inovaare

Job description

Remote

Hi, we're Oscar. We're hiring an Associate Director, Appeals & Grievances to join our team.

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:

The Associate Director, Escalations — Administrative Complaints, Grievances & Appeals (CGA) provides strategic leadership and operational oversight for Oscar's non-clinical Administrative CGA and Elite Member Champion Team (MCT) operations. This role is responsible for driving operational excellence and regulatory compliance across all lines of business, and utilizes Lean methodologies and capacity-based staffing models to maintain strict adherence to federal (CMS) and state turnaround times. The Associate Director, Escalations — Administrative CGA will lead high-performing teams through complex administrative member and provider issue resolutions, leverage case data to mitigate reputational risk, and collaborate with cross-functional partners in Claims, Network, Legal, and Compliance to eliminate root causes and proactively reduce overall escalation volume while fostering a strong talent pipeline.

You will report into the Senior Director Member & Provider Programs.

Work Location:

This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; Illinois; Iowa; Kansas; Michigan; Missouri; Nebraska; New Jersey; North Carolina; Ohio; California, Pennsylvania; South Carolina; Tennessee; Texas; or Virginia. 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 in the states of California, Connecticut, New Jersey, New York, and Washington is: $123,372.00- $161,925.75 per year. The base pay for this role in all other locations is: $111,034.80- $145,733.18 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program and annual performance bonuses.

Responsibilities:

• You will lead operational goals for CGA and Escalation teams, maintaining full accountability for compliance and quality metrics across all lines of business.
• Develop a multi-tiered team of managers, lead, and specialists using structured coaching frameworks and clear performance accountability to foster high engagement.
• Be the ultimate resolution authority for high-visibility, high-risk administrative complaints coming from senior leadership, regulatory bodies, and social channels.
• Establish and enforce standardized evaluation, escalation, and resolution workflows to ensure seamless end-to-end case ownership and eliminate friction.
• Maintain constant audit readiness and act as the primary operational lead for CMS, state Department of Insurance (DOI), and internal compliance audits.
• Partner with Claims, Network, Legal, and Compliance teams to turn case data insights into systemic root-cause solutions.
• Maximize operational efficiency and cost-effectiveness by using workforce data, capacity staffing models, and Lean methodologies.
• Manage delegated vendor entities to ensure full adherence to contractual, regulatory, and quality CGA standards.
• Present performance metrics, operational trends, and strategic compliance recommendations to executive leadership.
• Compliance with all applicable laws and regulations.
• Other responsibilities as assigned.

Requirements:

• 7+ years of progressive experience in healthcare operations, specifically focusing on healthcare compliance, complaints, grievances, or appeals (A&G).
• 4+ years of people management experience, including leading and developing other supervisors, team leads, or managers in a high-volume operations environment.
• Advanced knowledge and equivalent experience with Commercial Insurance, Medicare/Medicaid, and Affordable Care Act (ACA) rules and regulations relating to administrative Grievance & Appeals processes.
• Experience leading or representing operational teams during CMS, state-level, or other regulatory audits.
• Experience using operational data to lead decision-making, manage capacity, and implement process improvements.
• Bachelor's Degree or 4 years of equivalent experience.
• Operational Excellence Certification (Lean Six Sigma Green/Black Belt or equivalent).
• Experience leading remote or multi-site teams in a collaborative, fast-paced environment.
• Experience with data visualization tools (Tableau, Looker) and specialized case management systems (such as Inovaare or Jira).
• Advanced Degree (MBA, Master of Health Administration, or Juris Doctor).

This is an authentic Oscar Health job opportunity.

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.

Artificial Intelligence (AI):

Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts.

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 ([e-mail]) to make the need for an accommodation known.

California Residents:

For information about our collection, use, and disclosure of applicants’ personal information as well as applicants’ rights over their personal information, please see our Privacy Policy .

Oscar Health is authorized to do business in many, but not all, states. If you are not located in or willing to relocate to a state where Oscar is registered, you will not be eligible for employment. The approved states for this role are listed in the job posting.

Voluntary Self-Identification

For government reporting purposes, we