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Oscar Health // health insurance
New York, New York    Posted: Saturday, April 25, 2020
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Hi, were Oscar. Were a fully licensed health insurer. Our goal is to make healthcare simple, transparent, & human.

Were changing how health insurance works by creating a health care experience thats intuitive & puts people, not cost or workflows, first. Were using a consumer-focused & tech-driven approach to do so. This positions us uniquely in the space & creates one of the biggest opportunities in healthcare.

We brought together leaders from top technology, service & healthcare companies to deliver on our promise & seize this opportunity. We all work side by side in a collaborative, energetic, & creative environment. The result: better people, better ideas, & better healthcare.

What is the Position?

In this role, you will expand & manage a Special Investigations Unit (SIU). Your mandate will include the prevention of fraud, waste, and/or abuse (FWA), & the investigation & resolution of reports of potential FWA, thus generating return on Oscars investment in the SIU through savings & recoupments. In so doing, you will develop a team structure & investigative processes that can scale with Oscars expansion. You will design & lead cross-functional initiatives, building Oscars medical & pharmacy anti-FWA efforts in collaboration with the Data, Insurance Operations, Legal, Network, Clinical, & Tech teams. Finally, you will not only leverage your own experience & industry-standard practices to help Oscar benchmark its FWA activities, but also demonstrate innovation & creativity in exceeding these benchmarks as you make a meaningful impact on the organizations bottom line.

This role reports to Oscars New York-based Vice President of Compliance & Regulatory Affairs.

Deliverables: What you will achieve

During the first 6 weeks you will:

  • Develop a baseline understanding of Oscars current anti-FWA efforts, including stakeholders, strengths, weaknesses, & gaps
  • Read & review Oscars fraud plans on file with state regulators
  • Engage & build relationships with key internal partners, including but not limited to the Data, Insurance Operations, Legal, Network, Clinical, & Tech teams
  • Develop & initiate a hiring plan for open SIU positions
  • Embody Oscars vision of customer orientation & lean operations

By the end of month 3, you will:

  • Execute on your hiring plan
  • Work with internal stakeholders to shape & implement an FWA Roadmap (addressing both medical & pharmacy spend) for the remainder of 2020 & beyond
  • Set operational & financial targets for the SIU through the end of 2020
  • Review and, where appropriate, amend the FWA content, tracking, & execution of all internal onboarding & education programs

On an ongoing basis you will:

  • Set & meet targets which should, at least initially, increase year-over-year for (medical & pharmacy) FWA-driven recoupments & savings
  • Design & implement measurable, repeatable, & scalable tools & processes to fight FWA, always identifying opportunities for efficiency & automation
  • Stay abreast of industry developments, new schemes, & technological & regulatory developments, in order to implement targeted & responsive anti-fraud efforts
  • Foster widespread engagement by internal & external stakeholders with Oscars FWA program
  • Ensure that Oscar meets its legal & regulatory obligations related to FWA
  • Make referrals to, & where appropriate maintain relationships with, regulatory & law enforcement officials
  • Support & chart growth paths for your team members
  • Drive the culture at Oscar through your daily actions & leadership

What leads to success in this role?

Must-have qualities include:

  • (Legal requirement) A bachelors degree in Criminal Justice or a related field, OR five years of insurance claims investigation experience and/or professional investigation experience with law enforcement agencies, OR seven years of professional investigation experience involving economic or insurance-related matters
  • 7+ years total work experience in insurance, health care, tech, investigations, and/or law enforcement
  • Knowledge of applicable fraud statutes & regulations, & of CMS guidelines
  • Experience managing internal teams, external delegates & cross-functional initiatives
  • High integrity, as demonstrated by appropriate treatment of confidential information, adherence to policies, rules & regulations, professional conduct in dealing with internal & external parties, & sensitivity to target populations
  • Outstanding structured, systematic, & critical thinking
  • A desire to eliminate waste while driving operational excellence

Preferred qualifications include:

  • CFE, CAFP, or similar
  • Experience with HIPAA, data privacy, and/or data security processes
  • Experience working with regulators governing (public or private) health insurance carriers

We think you will love this job if you...

  • Are passionate about systematizing processes & building from the ground up
  • Have insatiable curiosity, a passion for health care, & a desire to seek the truth
  • Are willing to master the detail but can also zoom out to understand the big picture
  • Like to experiment & iterate on creative solutions to complex problems
  • Have acute attention to detail & always strive for perfection when writing formal documents
  • Get things done, even if its crunch time

At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we work to cultivate an environment where exceptional people can be their most authentic selves & find both belonging & support. We're on a mission to change healthcare -- an experience made whole by your unique background & perspectives.

Oscar applicants are considered solely based on their qualifications, without regard to applicants disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team ( to make the need for an accommodation known.

Pay Transparency Policy: Oscar's Pay Transparency Policy ensures that you won't be discharged or discriminated against based on whether you've inquired about, discussed, or disclosed your pay. Read the full policy here.

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