Director, SIU

Hi, we're Oscar. We're hiring a Director of SIU to join our SIU team.

Oscar is the first health insurance company built around a full stack technology platform and a focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family.

About the role

The Director, Special Investigations Unit (SIU) executes on Oscar’s fraud prevention program by setting and meeting operational and financial targets while upholding legal and regulatory obligations. 

You will report to the VP of Compliance.

Work Location:

Oscar is a blended work culture where everyone, regardless of work type or location, feels connected to their teammates, our culture and our mission.

If you live within commutable distance to our New York City office (in Hudson Square), our Tempe office (off the 101 at University Dr), or our Los Angeles office (in Marina Del Rey), you will be expected to come into the office at least two days each week. Otherwise, this is a remote / work-from-home role.

You must reside in one of the following states: Alabama, Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change. #LI-Remote

Pay Transparency:

The base pay for this role in the states of California, Connecticut, New Jersey, New York, and Washington is: $131-200 - $172,200 per year. The base pay for this role in all other locations is: $118,080 - $154,980 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program, company equity grants and annual performance bonuses.

Responsibilities

• Work with senior leadership to maintain and revise procedures, fraud, waste, and abuse plans, annual audit work plans, including department guidance memos, and training and educational materials.
• Drive the development of improvement strategies through the audit process and provide recommendations for system enhancement to enhance investigative outcomes and performance.
• Oversee the tracking, reporting, and follow ups on overpayments and recoveries; Maintain current, in-depth knowledge of all Oscar benefits, payment policies, provider network, configuration issues, and industry billing practices.
• Provide direct accountability for SIU case inventory management ensuring all recoveries are processed and promptly; Leads business requirement process and reporting to ensure notification of case activity to the appropriate regulatory and/or law enforcement agency.
• Lead the engagement and escalation framework for SIU Identifies, and escalates issues.
• Ensure investigations progress with minimal delays and in adherence with state and/or federal requirements. 
• Manage external engagements and related to requests from federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters.
• Partner with other department leaders and Oscar senior leaders in the planning, and coordination of department specifics and programs.
• Manage SIU team including hiring, training, professional development, performance management, work allocation, scheduling, and related supervisory activities.
• Facilitate team meetings and may lead and represent the SIU in various state and/or federal FWA related regulatory meetings.
• Develop and oversee the production of standard KPIs to monitor and report on overall department metrics and inventory management.
• Ensure that Oscar meets its legal and regulatory obligations related to FWA; Make referrals to, and maintain relationships with, regulatory and law enforcement officials
• Compliance with all applicable laws and regulations
• Other duties as assigned

Qualifications

• A bachelor’s degree in Criminal Justice or a related field, OR 10 years of insurance claims investigation experience and/or professional investigation experience with law enforcement agencies, OR 10 years of professional investigation experience involving economic or insurance-related matters
• 10+ years’ total work experience in insurance, health care, tech, investigations, and/or law enforcement
• 10+ years of experience managing our teams, external delegates and programs Knowledge of applicable fraud statutes and regulations, and of CMS guidelines

Bonus Points

• Certification applicable to this work i.e., Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified AML [Anti-Money Laundering] and Fraud Professional (CAFP), other coding certifications or similar
• Knowledge of applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity
• Experience working in health insurance specifically with claims processing, billing, reimbursement, or provider contracting.
• Experience with HIPAA, data privacy, and/or data security processes
• Experience working with regulators governing (public or private) health insurance carriers