Hi, we're Oscar. We're hiring a Specialist, Admin Complaints, Grievances & Appeals to join our Complaints, Grievances & Appeals team.

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

About the role:

You will be responsible for the comprehensive management & resolution of complex administrative member and/or provider grievances & appeals. You will serve as a subject matter expert on non-clinical case resolution, focusing on sensitive member issues such as claims concerns, access barriers, benefits concerns & complex service inquiries. You will drive the resolution process to meet regulatory standards set by the health plan's governing bodies, while championing member satisfaction & retention.

You will report into the Associate Director, Member & Provider Escalations.

Work Location: This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; or Texas. While your daily work will be completed from your home office, occasional travel may be required for team meetings & company events. #LI-Remote

Pay Transparency: The hourly rate for this role is: $24.00 per hour. You are also eligible for employee benefits & monthly vacation accrual at a rate of 15 days per year.

Responsibilities:

• Follow established workflows to acknowledge, log, & perform initial triage on complex or escalated administrative grievances from members and/or providers
• Conduct thorough, multi-faceted investigations by gathering & analyzing internal data, call logs, correspondence, etc.
• Use workflows to reconstruct complex event timelines involving prior authorizations, claims processing, & system-based adjudication edits to accurately determine the root cause of member and/or provider issues.
• Liaise with internal departments, such as Member Services, Eligibility & Benefits, & Claims, to obtain necessary information for complete case resolution.
• Based on investigative findings, determine a resolution strategy that is both fair & compliant with company & regulatory guidelines, utilizing established workflows.
• Escalate the issue to leadership for further guidance on resolution strategy, as needed
• Draft clear, accurate, complete resolution letters, ensuring all required regulatory elements are included
• Maintain meticulous & comprehensive case files in the case management system to ensure a clear & complete audit trail for each case
• Monitor & manage case timelines to ensure strict adherence to all federal & state mandated deadlines
• Compliance with all applicable laws & regulations
• Other duties as assigned

Requirements:

• 1+ years of professional experience in a regulated industry, such as healthcare, insurance
• 1+ years of experience independently managing a demanding caseload with multi-step workflows, from initial intake through investigation, resolution, & final documentation, while meeting competing priorities.
• 1+ years of experience with directly managing escalated customer, member or provider cases
• 1+ years of experience with drafting & issuing formal written communication to member or providers
• 1+ years of experience working in a highly structured, workflow driven, environment

Bonus points:

• Bilingual in Spanish (reading & writing)
• Bachelor's degree
• Experience in health care administration.
• Involvement in departmental or cross-functional process improvement or quality initiatives.