Associate Director – Appeals & Grievances

Job not on LinkedIn

🔥 4 minutes ago

🌵 Arizona, California, +15 more states – Remote

🌵 Arizona – Remote 🏄 California – Remote 🐊 Florida – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🌾 Nebraska – Remote 🏖️ New Jersey – Remote 🌲 North Carolina – Remote 🏈 Ohio – Remote 🚗 Michigan – Remote 🏰 Missouri – Remote 🔔 Pennsylvania – Remote 🌴 South Carolina – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⚔️ Virginia – Remote

💵 $111k - $145.7k / year

⏰ Full Time

🟠 Senior

👔 Director

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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Oscar Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2012

⚕️ Healthcare Insurance

🏥 Healthcare

💰 $355M Post-IPO Debt - Oscar Health on 2025-09

Healthcare Insurance • Healthcare

Oscar Health is a technology-driven health insurance company that provides individual, family, and small-group health plans in multiple U. S. states. Oscar combines traditional insurance underwriting with digital-first services — a consumer-facing app, 24/7 virtual urgent care, prescription delivery (including $3 meds in many plans), and dedicated Care Teams — and also operates Oscar Primary Care in some markets. The company emphasizes accessible, affordable, high-quality care and uses AI to improve member experience and care delivery. Insurance policies are underwritten by Oscar's state insurance subsidiaries and the company offers both HMO and other plan types across its markets.

📋 Description

• Lead operational goals for CGA and Escalation teams, maintaining accountability for compliance and quality metrics across all lines of business • Develop managers, leads, and specialists using structured coaching frameworks and performance accountability • Serve as the resolution authority for high-visibility, high-risk administrative complaints from senior leadership, regulatory bodies, and social channels • Establish and enforce standardized evaluation, escalation, and resolution workflows • Maintain 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 • Use workforce data, capacity staffing models, and Lean methodologies to maximize operational efficiency and cost-effectiveness • Manage delegated vendor entities for contractual, regulatory, and quality CGA standards • Present performance metrics, operational trends, and strategic compliance recommendations to executive leadership • Comply with all applicable laws and regulations • Perform 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)

🏖️ Benefits

• Employee benefits • Unlimited vacation program • Annual performance bonuses • Medical benefits • Dental benefits • Vision benefits • 11 paid holidays • Paid sick time • Paid parental leave • 401(k) plan participation • Life insurance • Disability insurance • Paid wellness time and reimbursements • Remote work from a home office • Occasional travel for team meetings and company events