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Salary: USD 216,108 - 283,642 / annual
Oscar Health is seeking an Associate Medical Director, Regulatory Management to join the Clinical Affairs team. This role provides strategic and operational leadership for provider clinical regulatory programs and credentialing operations, driving clinical policy guidance and ensuring enterprise compliance with NCQA, CMS, state, and accreditation standards.
You will report to the Vice President of Clinical Affairs and lead the Clinical Policy Compliance team and Clinical Coding Center of Excellence. Key responsibilities include:
- Building and leading high-impact compliance, quality, and regulatory strategy across the organization
- Developing clinical regulatory policies, Benefit Interpretation Policies (BIPs), and operational SOPs aligned with state and federal laws
- Chairing the Credentialing, Peer Review, and Population Health Management sub-committee, driving case reviews and reporting KPIs to quarterly Quality Improvement meetings
- Overseeing practitioner and facility credentialing to ensure NCQA standards, CMS requirements, and state regulation compliance
- Partnering with Network and Market Management executives to accelerate provider onboarding while maintaining credentialing integrity
- Collaborating on Quality Improvement initiatives for Clinical Review Operations, optimizing Inter-Rater Reliability (IRR) processes and Potential Quality Issue (PQI) workflows
- Identifying and resolving operational bottlenecks to streamline processes and enhance member and provider satisfaction
- Serving as subject matter expert on state and federal healthcare regulations, monitoring legal developments and translating changes into proactive operational updates
This is a fully remote position open to candidates residing in Atlanta, Georgia, though future hybrid arrangements at the Atlanta hub office may be considered.
**Requirements:**
- 7+ years of progressive healthcare experience, including leadership responsibility
- 3+ years managing provider credentialing within a health plan, managed care organization, or large healthcare system
- 3+ years knowledge of NCQA credentialing standards, CMS health plan regulatory requirements, and applicable federal and state regulations
- 1+ years experience managing and working with clinical coding taxonomies
- Demonstrated experience leading operational improvement initiatives and managing cross-functional partnerships
- Strong knowledge of provider data management, credentialing systems, and primary source verification processes
- Proven ability to lead teams, manage competing priorities, and deliver measurable operational results
- MD or DO with current unrestricted license to practice medicine (required)
- Must maintain active board certification
- Willing to obtain additional state licensure with Oscar's support
**Bonus qualifications:**
- Licensure in multiple Oscar states
- Master's degree or advanced certificate
- Prior experience with Utilization Management
