At Oscar, were working hard to provide the kind of health insurance we want for ourselves. Oscar is changing how consumers experience healthcare - & clinical & operational excellence is the foundation of it all.
When you come in, you will be a leader on our Clinical Operations team; one of Oscars most important functions. This team encourages evidence-based practice through utilization review & appeals & advocates for our members through thorough grievance resolution. This ensures our members get access to the right care - particularly those who need it most.
In this role, you will lead our Clinical Review & Grievance & Appeals functions in ensuring our members have the best health care experience. You will lead an organization of over 50 high performing individuals to ensure they have the necessary support, & are empowered to continue to move the needle for our members & provider partners.
At Oscar, we never build alone. This role will partner heavily with all of the key stakeholder functions at Oscar including the Product, Insurance Operations, Engineering, Concierge, Population Health & Network teams.
Ideally, you have remarkable experience leading a clinical, quality-driven service organization & a notable track record of improving operational metrics & customer experience. Additionally, you must be a systematic thinker & just get things done. Experience in owning, driving & improving operational processes is a must.
Your key responsibilities will be to:
- Own the end-to-end operations for utilization review, grievances & appeals ensuring operational excellence, clinical quality & regulatory compliance
- Build best-in-class lean processes & leverage technology to drive automation, speed, & quality.
- Drive continuous improvement to enable the organization to scale efficiently & effectively in line with Oscars long-term vision
- Form strong working relationships with key internal stakeholders across the company & understand the impact of our contractual terms on their work streams & inform our network strategies.
Key components for success include:
- 10+ years of work experience in the healthcare industry preferably at a payer or health system
- Experience & understanding of the government market, specifically Medicare.
- Experience & understanding of CMS regulations & interfacing with regulators.
- Direct experience with & a deep understanding of grievances & appeals, medical utilization & healthcare operations
- A strong analytical background & the ability to quickly digest & evaluate complex analyses & operational workflows, with a keen eye for detail
- Ability to manage complex projects across the organization as well as to develop, motivate, & grow a team
- Strong leadership & other interpersonal skills needed to lead & scale a department & communicate clearly at the executive level
- Capability to work within a standardized workflow while also being able to handle unforeseen problems, craft ad-hoc solutions, & leverage solutions to improve existing workflows
- Highly systematic thinking as shown demonstrated by prior work or experience (lean operations, consulting, MBA, project management, etc).
- Understanding of departmental budgeting & operating a business unit while exercising fiduciary responsibility.
A plus, but not required:
- An MBA or other professional degree from a competitive program with a clear track record of excellence
- Experience with growth-stage enterprises & scaling departments & processes
- Strong ability to influence others even without direct authority.
- Building, coaching, developing teams.
- Can drive forward even amidst ambiguity (people, process, data) & complexity.
- Love coaching & developing people - & vendors.