Associate Director, Special Investigations Unit

Summary

Join Oscar's Special Investigations Unit as an Associate Director and oversee the development and management of SIU programs. You will lead a team, develop strategies to detect and mitigate fraud, waste, and abuse (FWA), and ensure compliance with state and federal regulations. This role requires experience in health plan compliance, managing complex projects, and possessing a CPC certification. The position offers a blended work culture with remote options and a competitive salary and benefits package, including performance bonuses, unlimited vacation, and comprehensive health insurance.

Requirements

• Bachelor's Degree or equivalent work experience
• 1+ year experience in health plan compliance
• 2+ years experience with State DOI health insurance rules and regulations, CMS ACA rules and requirements, CMS requirements
• 2+ years experience managing high volume and complicated projects, keeping track of details, and staging work
• Current Certified Professional Coder (CPC) certification

Responsibilities

• Support the Director to develop procedures, fraud, waste, and abuse plans, annual audit work plans, department guidance memos, and training and educational materials for internal and external recipients
• Help evaluate the effectiveness of existing processes and make recommendations for improvements, including system enhancements, to enhance outcomes and performance
• Develop relationships with departmental leaders to understand and influence business operations, work collaboratively and cross-functionally with SIU partner departments
• Approve metrics tracking and reporting before distribution to the Director
• Manage SIU inventory ensuring audit and investigation steps are processed and promptly. Ensure investigations and audits progress in adherence with state and/or federal requirements
• Help manage external engagements and related to requests from federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters
• Manage team including hiring, training, professional development, performance management, work allocation, scheduling, and related supervisory activities
• Facilitate team meetings and may lead and represent the SIU in multiple internal or external forums including state and/or federal FWA related regulatory meetings
• Ensure that Oscar meets its legal and regulatory obligations related to FWA; Make referrals to, and maintain relationships with, regulatory and law enforcement officials; Maintain current, in-depth knowledge of all Oscar benefits, payment policies, provider network, configuration issues, and industry billing practices
• Compliance with all applicable laws and regulations
• Other duties as assigned

Preferred Qualifications

• CHC, CCEC, or similar
• Fluency with State DOI audit and/or reporting obligations
• State DOI audit management experience
• Experience in a start-up and/or health tech environment
• Experience in a TPA setting

Benefits

• Medical, dental, and vision benefits
• 11 paid holidays
• Paid sick time
• Paid parental leave
• 401(k) plan participation
• Life and disability insurance
• Paid wellness time and reimbursements
• Annual performance bonuses
• Oscar's unlimited vacation program