Associate, Claims Regulatory Operations Specialist

4 weeks ago

New York, New York, United States Oscar Health Full time
Job Title: Associate, Claims Regulatory Operations

We are seeking a highly skilled Associate, Claims Regulatory Operations to join our Claims Quality team at Oscar Health. As a key member of our team, you will play a crucial role in supporting compliance within Provider Operations by analyzing challenges, coordinating responses, and delivering positive outcomes based on inputs from stakeholders.

About the Role

The Associate, Claims Regulatory Operations will be responsible for advancing compliance efforts by conducting detailed data analysis, managing document reviews, overseeing the delivery of Market Conduct Exam exhibits/narratives and the policies & procedures review process within Operations. You will report to the Sr. Manager, Payment Quality.

Responsibilities
  • Collaborate with team members and senior leaders to address process gaps and improvements.
  • Perform data pulls and conduct detailed analysis to support compliance initiatives.
  • Develop trusting relationships with internal and external stakeholders through effective communication and collaboration.
  • Review and submit detailed narratives and reports to communicate compliance findings and updates, including responses to Regulator/NCQA requests and examinations.
  • Oversee the Policies & Procedures review process within Operations, ensuring that all policies and procedures are up-to-date and meet internal requirements as outlined by Compliance team.
  • Support Oscar team members through knowledge sharing, process documentation, and tooling development.
  • Assist in preparing for Market Conduct Exams and other regulatory reviews.
  • Stay informed on business requirements and act on regulatory updates guided by Oscar's Compliance team to ensure adherence to effective processes and procedures.
Qualifications
  • Demonstrated understanding of Provider operations in the health payer industry.
  • 3+ years of relevant experience working with operational compliance, regulatory, and data analysis within Claims.
  • 3+ years experience designing and improving workflows.
Bonus Points
  • 3+ years experience working with regulatory bodies and Market Conduct Exams.
  • Experience managing complicated business challenges: developing understanding, distilling and communicating that understanding to technical and non-technical audiences.
  • An academic and professional background in engineering, data, or healthcare.
  • Knowledge management, training, or content development in operational settings.
  • Process Improvement or Lean Six Sigma certification.
  • Structured, systematic, and critical thinking.
  • Strong verbal and written communications.
  • 3+ years experience using data software (e.g. Excel, VGA, Macros, SQL and/or Python) to manipulate and analyze large data sets to solve business problems.

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