Director, Special Investigations Unit at Oscar
Hi, we’re Oscar. We’re a fully licensed health insurer. Our goal is to make healthcare simple, transparent, and human.
We’re changing how health insurance works by creating a health care experience that’s intuitive and puts people, not cost or workflows, first. We’re using a consumer-focused and tech-driven approach to do so. This positions us uniquely in the space – and creates one of the biggest opportunities in healthcare.
We brought together leaders from top technology, service and healthcare companies to deliver on our promise and seize this opportunity. We all work side by side in a collaborative, energetic, and creative environment. The result: better people, better ideas, and better healthcare.
What is the Position?
In this role, you will expand and manage a Special Investigations Unit (SIU). Your mandate will include the prevention of fraud, waste, and/or abuse (FWA), and the investigation and resolution of reports of potential FWA, thus generating return on Oscar’s investment in the SIU through savings and recoupments. In so doing, you will develop a team structure and investigative processes that can scale with Oscar’s expansion. You will design and lead cross-functional initiatives, building Oscar’s medical and pharmacy anti-FWA efforts in collaboration with the Data, Insurance Operations, Legal, Network, Clinical, and Tech teams. Finally, you will not only leverage your own experience and industry-standard practices to help Oscar benchmark its FWA activities, but also demonstrate innovation and creativity in exceeding these benchmarks as you make a meaningful impact on the organization’s bottom line.
This role reports to Oscar’s New York-based Vice President of Compliance and Regulatory Affairs.
Deliverables: What you will achieve
During the first 6 weeks you will:
- Develop a baseline understanding of Oscar’s current anti-FWA efforts, including stakeholders, strengths, weaknesses, and gaps
- Read and review Oscar’s fraud plans on file with state regulators
- Engage and build relationships with key internal partners, including but not limited to the Data, Insurance Operations, Legal, Network, Clinical, and Tech teams
- Develop and initiate a hiring plan for open SIU positions
- Embody Oscar’s vision of customer orientation and lean operations
By the end of month 3, you will:
- Execute on your hiring plan
- Work with internal stakeholders to shape and implement an FWA Roadmap (addressing both medical and pharmacy spend) for the remainder of 2020 and beyond
- Set operational and financial targets for the SIU through the end of 2020
- Review and, where appropriate, amend the FWA content, tracking, and execution of all internal onboarding and education programs
On an ongoing basis you will:
- Set and meet targets – which should, at least initially, increase year-over-year – for (medical and pharmacy) FWA-driven recoupments and savings
- Design and implement measurable, repeatable, and scalable tools and processes to fight FWA, always identifying opportunities for efficiency and automation
- Stay abreast of industry developments, new schemes, and technological and regulatory developments, in order to implement targeted and responsive anti-fraud efforts
- Foster widespread engagement – by internal and external stakeholders – with Oscar’s FWA program
- Ensure that Oscar meets its legal and regulatory obligations related to FWA
- Make referrals to, and where appropriate maintain relationships with, regulatory and law enforcement officials
- Support and chart growth paths for your team members
- Drive the culture at Oscar through your daily actions and leadership
What leads to success in this role?
Must-have qualities include:
- (Legal requirement) A bachelor’s 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 and regulations, and of CMS guidelines
- Experience managing internal teams, external delegates and cross-functional initiatives
- High integrity, as demonstrated by appropriate treatment of confidential information, adherence to policies, rules and regulations, professional conduct in dealing with internal and external parties, and sensitivity to target populations
- Outstanding structured, systematic, and 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 and building from the ground up
- Have insatiable curiosity, a passion for health care, and 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 and iterate on creative solutions to complex problems
- Have acute attention to detail and always strive for perfection when writing formal documents
- Get things done, even if it’s 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 and find both belonging and support. We're on a mission to change healthcare -- an experience made whole by your unique background and perspectives.
Oscar applicants are considered solely based on their qualifications, without regard to applicant’s disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team ([email protected]) 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.