Hi, we're Oscar. We're hiring a Senior Director, Payment Integrity (Edits) to join our Payment Integrity team.

About the role

As the Senior Director of Payment Integrity, this role is responsible for continuous improvement and compliance of pre-payment claims services and solutions, with focus on editing and FWA. Responsible for establishing a best in class standard for pre-payment payment integrity operational performance at Oscar. You will build the department function and drive quantitative and qualitative excellence across pre-payment services.

You will report into Vice President of Payment Integrity. You will be management level: Senior Director

This is a work-from-home/remote role. You must reside in one of the following states: Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Iowa, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change.

The base pay for this role in the states of California, Connecticut, New Jersey, New York, and Washington is: $192,000 - $252,000 per year. The base pay for this role in all other locations is: $172,800 - $226,800 per.year You are also eligible for employee benefits, monthly vacation accrual up to 10 days per year, participation in Oscar's unlimited vacation program, company equity grants and annual performance bonuses.

Responsibilities

● Set, drive and execute on the pre-payment payment integrity strategy and vision to enhance the program’s overall value, including determining and uncovering new opportunities

● Collaborate with Operations, Technology, and Network team leadership to identify and implement pre-payment editing performance strategies

● Manage payment integrity vendor relationships to build best in class program for editing and FWA

● Lead creation of short- and long-term roadmap planning process to meet organization goals, identifying important resources and requirements to meet plans' goals

● Establish and set checks to ensure compliance with industry regulations, internal policies and best practice principles around claims processing and editing are being followed

● Oversee monitoring of pre-payment editing to ensure that claims processing meets performance metrics around quality, member and provider satisfaction

● Own and continuously evaluate financial performance of the department

● Drive the budgeting process and the fiscal performance for the team in association with the leadership team

● Compliance with all applicable laws and regulations

Qualifications

• A bachelor's degree or commensurate 4 years of experience
• 15+ years experience in a cross-functional operations environment
• 3+ years of experience working at a health plan/payer
• Extensive knowledge of claims operations and processing, insurance products, contracts, and regulatory and policy language
• Experience analyzing and improving processes and workflows
• Experience working with technical teams (i.e. engineering and product) to communicate our requirements, design tooling, and support technical troubleshooting
• People management skills and team leadership experience with ability to prioritize, allocate work and manage across multiple high-value projects at once
• Experience forming data-driven, concrete answers in a world with imperfect information
• Excellent leadership and communication skills to drive decision-making and results across multiple partners

Bonus Points

• Certified professional coder or other clinical credentials