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Salary: USD 111,034.8 - 161,925.75 / annual
Oscar Health is seeking an Associate Director, Appeals & Grievances to lead strategic operations for the company's non-clinical Administrative Complaints, Grievances & Appeals (CGA) and Elite Member Champion Team (MCT). This role provides operational oversight across all lines of business, driving regulatory compliance and operational excellence.
You will report to the Senior Director of Member & Provider Programs and lead high-performing teams through complex administrative member and provider issue resolutions. Key responsibilities include:
• Lead operational goals for CGA and Escalation teams with full accountability for compliance and quality metrics across all lines of business
• Develop and mentor a multi-tiered team of managers, leads, and specialists using structured coaching frameworks and clear performance accountability
• Serve as the ultimate 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 to ensure seamless end-to-end case ownership
• Maintain audit readiness and serve as 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
• Maximize operational efficiency using workforce data, capacity staffing models, and Lean methodologies
• Manage delegated vendor entities to ensure adherence to contractual, regulatory, and quality CGA standards
• Present performance metrics, operational trends, and strategic compliance recommendations to executive leadership
Oscar is a technology-driven health insurance company founded in 2012, focused on serving members with a full-stack platform and relentless focus on customer experience.
The role is remote, open to candidates residing in: Arizona, California, Connecticut, Florida, Georgia, Illinois, Iowa, Kansas, Michigan, Missouri, Nebraska, New Jersey, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Washington. Occasional travel may be required for team meetings and company events.
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
BONUS QUALIFICATIONS:
• 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)
