Oscar Health - Associate Medical Director, Regulatory Management
Requirements
• 7+ years of progressive healthcare experience, including leadership responsibility. • 3+ years experience 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 lead measurable operational results. • Education: • MD or DO with a current unrestricted license to practice medicine is required. • License and Certification: • Reviewers must maintain necessary credentials to retain the position including maintaining active board certification. • Willing to obtain additional state licensure (with Oscar's support). • Licensure in multiple Oscar states. • Masters degree or advanced certificate. • Prior experience with Utilization management. • This is an authentic Oscar Health job opportunity.
Responsibilities
• Build and lead the Clinical Policy Compliance team and the Clinical Coding Center of Excellence, driving high-impact compliance, quality, and regulatory strategy across the organization. • Direct the development of clinical regulatory policies, Benefit Interpretation Policies (BIPs), and operational SOPs to ensure full alignment with state and federal laws, in partnership with other SMEs in the Office of Clinical Affairs. • Chair the Credentialing, Peer Review, and Population Health Management sub-committee, driving individual case reviews and reporting key performance metrics to quarterly Quality Improvement meetings. • Oversee practitioner and facility credentialing to guarantee compliance with NCQA standards, CMS requirements, and state regulations - verifying licenses, board certifications, and sanction histories. • Partner with Network and Market Management executives to accelerate provider onboarding and strategically resolve network gaps while maintaining strict credentialing integrity. • Collaborate on Quality Improvement for Clinical Review Operations, optimizing Inter-Rater Reliability (IRR) processes, clinical delegate audits, and Potential Quality Issue (PQI) workflows. • Identify and resolve operational bottlenecks to streamline processes, eliminate delays, and enhance member and provider satisfaction without compromising quality or compliance. • Serve as a subject matter expert on state and federal healthcare regulations, continuously monitoring legal developments and translating regulatory changes into proactive operational updates to maintain ongoing compliance. • Compliance with all applicable laws and regulations. • Other duties as assigned.
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