Remote Director

Summary

Join Oscar's SIU team as a Director of Special Investigations Unit (SIU) and execute on Oscar’s fraud prevention program by setting and meeting operational and financial targets while upholding legal and regulatory obligations.

Requirements

• A bachelor’s degree in Criminal Justice or a related field, OR 10 years of insurance claims investigation experience and/or professional investigation experience with law enforcement agencies, OR 10 years of professional investigation experience involving economic or insurance-related matters
• 10+ years’ total work experience in insurance, health care, tech, investigations, and/or law enforcement
• 10+ years of experience managing our teams, external delegates and programs Knowledge of applicable fraud statutes and regulations, and of CMS guidelines

Responsibilities

• Work with senior leadership to maintain and revise procedures, fraud, waste, and abuse plans, annual audit work plans, including department guidance memos, and training and educational materials
• Drive the development of improvement strategies through the audit process and provide recommendations for system enhancement to enhance investigative outcomes and performance
• Oversee the tracking, reporting, and follow ups on overpayments and recoveries; Maintain current, in-depth knowledge of all Oscar benefits, payment policies, provider network, configuration issues, and industry billing practices
• Provide direct accountability for SIU case inventory management ensuring all recoveries are processed and promptly; Leads business requirement process and reporting to ensure notification of case activity to the appropriate regulatory and/or law enforcement agency
• Lead the engagement and escalation framework for SIU Identifies, and escalates issues
• Ensure investigations progress with minimal delays and in adherence with state and/or federal requirements
• 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
• Partner with other department leaders and Oscar senior leaders in the planning, and coordination of department specifics and programs
• Manage SIU 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 various state and/or federal FWA related regulatory meetings
• Develop and oversee the production of standard KPIs to monitor and report on overall department metrics and inventory management
• Ensure that Oscar meets its legal and regulatory obligations related to FWA; Make referrals to, and maintain relationships with, regulatory and law enforcement officials
• Compliance with all applicable laws and regulations
• Other duties as assigned

Preferred Qualifications

• Certification applicable to this work i.e., Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML [Anti-Money Laundering] and Fraud Professional (CAFP), other coding certifications or similar
• Knowledge of applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity
• Experience working in health insurance specifically with claims processing, billing, reimbursement, or provider contracting
• Experience with HIPAA, data privacy, and/or data security processes
• Experience working with regulators governing (public or private) health insurance carriers

Benefits

• 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
• Paid wellness time and reimbursements