Associate Medical Director, Regulatory Management

This is a fully remote position, open to applicants in Florida.

📋 Description

• Establish and lead the Clinical Policy Compliance team along with the Clinical Coding Center of Excellence.

• Propel compliance, quality, and regulatory strategies throughout the organization.

• Guide the creation of clinical regulatory policies, Benefit Interpretation Policies (BIPs), and operational SOPs in accordance with state and federal regulations.

• Chair the sub-committee for Credentialing, Peer Review, and Population Health Management.

• Conduct individual case reviews and present key performance metrics at quarterly Quality Improvement meetings.

• Supervise practitioner and facility credentialing to ensure adherence to NCQA standards, CMS requirements, and state regulations.

• Validate licenses, board certifications, and sanction histories.

• Collaborate with Network and Market Management executives on provider onboarding and addressing network gaps.

• Work together on Quality Improvement for Clinical Review Operations, which includes IRR processes, clinical delegate audits, and PQI workflows.

• Identify and address operational bottlenecks.

• Act as a subject matter expert on state and federal healthcare regulations.

• Keep abreast of legal developments and transform regulatory changes into operational updates.

• Adhere to all relevant laws and regulations.

• Undertake additional duties as assigned.

⛳️ Requirements

• Over 7 years of progressive experience in healthcare, including leadership roles.

• At least 3 years of experience managing provider credentialing within a health plan, managed care organization, or large healthcare system.

• Minimum of 3 years of knowledge regarding NCQA credentialing standards, CMS health plan regulatory requirements, and relevant federal and state regulations.

• More than 1 year of experience managing and working with clinical coding taxonomies.

• Proven track record in leading operational improvement initiatives and managing cross-functional partnerships.

• In-depth knowledge of provider data management, credentialing systems, and primary source verification processes.

• Demonstrated capability to lead teams, juggle competing priorities, and achieve measurable operational outcomes.

• An MD or DO with a current unrestricted medical license is mandatory.

• Required credentials must be maintained, including active board certification.

• Openness to obtaining additional state licensure with support from Oscar.

🏝️ Benefits

• Comprehensive employee benefits.

• Unlimited vacation program.

• Annual performance bonuses.

• Medical, dental, and vision coverage.

• 11 paid holidays.

• Paid sick leave.

• Paid parental leave.

• Participation in a 401(k) plan.

• Life and disability insurance.

• Paid wellness time and reimbursements.

• Oscar's assistance in acquiring additional state licensure.