Associate Director of Claims Compliance

Oscar Health; New York (NY); On-site; USD 150,000 - 210,000; Full time

Benefits offered by this job

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Job summary

Oscar Health is seeking an Associate Director, Claims Compliance to lead a team of analysts focused on regulatory inquiries and exams. The role drives adherence to state and federal rules, partnering across Operations to strengthen claims compliance and performance.

You will report to the Senior Director, Claims Quality and Compliance, translating vision into actionable programs, and guiding cross-department initiatives to timely results and issue resolution.

Qualifications

• 7+ years of experience in claims operations and processing.
• Experience with regulatory agencies and regulatory requirements.
• 5+ years of people management and team leadership.
• Bachelor's degree or 4 years commensurate experience.
• Experience with benefit and contract interpretation or coding in professional/institutional billing.
• Experience managing claims across Medicare or Commercial products.
• Experience analyzing and improving processes and workflows.
• Experience collaborating with technical teams (engineering/product) to communicate requirements.

Responsibilities

• Lead a team of claims analysts specializing in regulatory compliance and investigations.
• Direct and coordinate aspects of Oscar claims processes including research and regulatory inquiries.
• Collaborate with regulators, Oscar's legal, audit, and regulatory compliance teams.
• Translate strategy into business plans to meet KPIs, targets and SLAs.
• Supervise and train managers and employees as needed.
• Influence departmental strategy with quantitative and qualitative insights.

Skills

Regulatory compliance

Leadership

Claims operations

Cross-functional collaboration

Data-driven decisions

Communication

Education

Bachelor's degree or equivalent experience

Job description

• Hi, we're Oscar. We're hiring a Claims Compliance Associate Director to join our Claims 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
• The Associate Director, Claims Compliance leads a team of analysts responsible for investigating and responding to regulatory inquiries, including market conduct exams
• This role is responsible for ensuring adherence to state and federal regulations, working directly with regulators on exams and investigations, and partnering across Insurance Operations and cross-functionally to ensure processes and workflows are in place to strengthen claims compliance
• The Associate Director transforms ideas from vision to implementation, with the goal of improving claims compliance and regulatory performance
• You will report into the Senior Director, Claims Quality and Compliance
• Direct and coordinate aspects of Oscar claims processes including but not limited to: research, adjustments, and regulatory inquiries
• Lead a team of claims analysts specializing in regulatory compliance, tasked with investigating regulatory inquiries and developing external responses
• Leverages industry background and knowledge of processes to influence others in sensitive complex situations while preserving relationships. Significantly influences departmental strategy by providing quantitative and qualitative inputs that drive organization success
• Translates the claims department's strategy into business plans and tactics in order to meet operational KPIs, targets and SLAs
• Creates necessary structure to achieve programmatic and departmental goals
• Understands and uses business and industry knowledge to inform strategy and execution
• Supervise and train managers and employees as needed
• Collaborate and communicate with other departments on claims issues, related projects and inter-departmental operations issues while developing effective, actionable solutions
• Effectively manage processes and inter departmental initiatives through a collaborative approach to ensure timely results or issue resolution
• Work cross collaboratively with various regulatory agencies, as well as Oscar's legal, audit, and regulatory compliance teams
• Compliance with all applicable laws and regulations
• Other duties as assigned

7+ years of demonstrated experience in claims operations and processing, insurance products, and regulatory and policy languageExperience forming data-driven, concrete answers in a world with imperfect informationProven background collaborating with regulatory agencies and strong familiarity with regulatory requirements5+ years of people management and team leadership experience with ability to prioritize, allocate work and manage across multiple high-value projects at onceBachelor's degree, or 4 years commensurate experienceExperience with benefit and contract interpretation or coding in professional/ institutional billing requirementsExperience managing claims across multiple product types ( i.e.Medicare or Commercial)Experience analyzing and improving processes and workflowsExperience working with technical teams (e.g. engineering and product) to communicate our requirements, design tooling, and support technical troubleshootingExcellent leadership and communication skills to drive decision-making and results across multiple partners