Associate Director, Special Investigations Unit

Hi, we're Oscar. We're hiring a Associate Director, Special Investigations Unit to join our SIU team.

Oscar is the first health insurance company built around a full stack technology platform and a focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family.

About the role

The Associate Director, Special Investigations Unit role oversees the development, and management of SIU programs conducting prepay and postpayment investigations to detect and eliminate potential fraud, waste, and abuse (FWA).  Leading people leaders and individual contributors, the Associate Director is tasked with the development of strategies for cross-functional detection and mitigation of FWA; creation of departmental processes aimed at evaluating Metrics, and progress towards established goals, ensuring appropriate procedures are in place to develop a successful SIU program.

You will report to the Director, SIU.

Work Location:

Oscar is a blended work culture where everyone, regardless of work type or location, feels connected to their teammates, our culture and our mission.

If you live within commutable distance to our New York City office (in Hudson Square), our Tempe office (off the 101 at University Dr), or our Los Angeles office (in Marina Del Rey), you will be expected to come into the office at least two days each week. Otherwise, this is a remote / work-from-home role.

You must reside in one of the following states: Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change. #LI-Remote

Pay Transparency:

The base pay for this role in the states of California, Connecticut, New Jersey, New York, and Washington is: $144,000 - $189,000 per year. The base pay for this role in all other locations is: $129,600 - $170,100 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program and annual performance bonuses.

Responsibilities

• Support the Director to develop procedures, fraud, waste, and abuse plans, annual audit work plans, department guidance memos, and training and educational materials for internal and external recipients. Help evaluate the effectiveness of existing processes and make recommendations for improvements, including system enhancements, to enhance outcomes and performance.
• Develop relationships with departmental leaders to understand and influence business operations, work collaboratively and cross-functionally with SIU partner departments.
• Approve metrics tracking and reporting before distribution to the Director.
• Manage SIU inventory ensuring audit and investigation steps are processed and promptly.  Ensure investigations and audits progress in adherence with state and/or federal requirements. 
• Help 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.
• Manage 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 multiple internal or external forums including state and/or federal FWA related regulatory meetings.
• Ensure that Oscar meets its legal and regulatory obligations related to FWA; Make referrals to, and maintain relationships with, regulatory and law enforcement officials; Maintain current, in-depth knowledge of all Oscar benefits, payment policies, provider network, configuration issues, and industry billing practices.
• Compliance with all applicable laws and regulations
• Other duties as assigned.

Qualifications

• A bachelor’s degree in Criminal Justice or a related field, OR 6+ years of insurance claims investigation experience and/or professional investigation experience with law enforcement agencies, OR 6+ years of professional investigation experience involving economic or insurance-related matters
• 6+ years’ total work experience in insurance, health care, tech, investigations, and/or law enforcement
• 3+ years of experience managing internal teams, external delegates and cross-functional initiatives Knowledge of applicable fraud statutes and regulations, and of CMS guidelines
• Current Certified Professional Coder (CPC) certification

Bonus Points

• 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