Associate Director, Appeals & Grievances

Praxy; Northern (KY); Hybrid; USD 111,000 - 146,000; Full time

Benefits offered by this job

Medical, dental & vision benefits

11 paid holidays

Paid sick time

Paid parental leave

401(k) plan participation

Life and disability insurance

Paid wellness time and reimbursements

Job summary

Oscar Health is seeking an Associate Director, Appeals & Grievances & Administrative CGA leader to drive strategic governance for non-clinical CGA operations. This executive role manages cross-functional teams, ensures regulatory compliance, and advances Lean-driven capacity planning while reducing escalation volume.

The role is remote across multiple states with travel as needed, reporting to the Senior Director, and offers performance bonuses and comprehensive benefits.

Qualifications

• 7+ years of healthcare operations experience focusing on compliance, complaints, grievances, or appeals.
• Proven track record leading remote or multi-site teams in fast-paced settings.
• Experience with CMS and state regulatory audits.
• Strong data visualization and case management tooling experience.
• Bachelor's degree or equivalent experience; Lean Six Sigma certification.

Responsibilities

• Lead CGA and Escalations teams to meet compliance and quality metrics.
• Develop multi-tier management and coaching framework.
• Serve as resolution authority for high-visibility complaints.
• Standardize workflows for end-to-end case ownership.
• Maintain audit readiness with CMS/DOI and internal audits.
• Collaborate with Claims, Network, Legal, Compliance to reduce escalations.
• Improve efficiency using Lean methods and capacity planning.
• Oversee delegated vendors to ensure CGA standards.
• Present metrics and recommendations to senior leadership.

Skills

Healthcare operations

Regulatory compliance

Remote team leadership

Data-driven decision making

Lean Six Sigma

Education

Bachelor's Degree

MBA/MPH/JD

Tools

Tableau

Looker

Jira

Inovaare

Job description

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 ([email removed]) 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 .

Pay

base pay for this role in all other locations is: $111,034.80- $145,733.18