Associate Medical Director, Regulatory Management

The role

This role provides strategic and operational leadership for provider clinical regulatory programs and credentialing operations. The leader drives clinical policy guidance and ensures enterprise compliance with NCQA, CMS, state, and accreditation standards.

What you will do

• Build and lead the Clinical Policy Compliance team and the Clinical Coding Center of Excellence
• Direct the development of clinical regulatory policies, Benefit Interpretation Policies (BIPs), and operational SOPs
• Chair the Credentialing, Peer Review, and Population Health Management sub-committee
• Oversee practitioner and facility credentialing to guarantee compliance with NCQA standards, CMS requirements, and state regulations
• Partner with Network and Market Management executives to accelerate provider onboarding
• Collaborate on Quality Improvement for Clinical Review Operations
• Identify and resolve operational bottlenecks to streamline processes
• Serve as a subject matter expert on state and federal healthcare regulations
• Compliance with all applicable laws and regulations
• Other duties as assigned

Required qualifications

• 7+ years of progressive healthcare experience, including leadership responsibility
• 3+ years experience managing provider credentialing within a health plan, managed care organization, or large healthcare system
• 3+ years knowledge of NCQA credentialing standards, CMS health plan regulatory requirements, and applicable federal and state regulations
• 1+ years experience managing and working with clinical coding taxonomies
• Demonstrated experience leading operational improvement initiatives and managing cross-functional partnerships
• Strong knowledge of provider data management, credentialing systems, and primary source verification processes
• Proven ability to lead teams, manage competing priorities, and lead measurable operational results
• MD or DO with a current unrestricted license to practice medicine
• Maintain active board certification

Nice to have

• Licensure in multiple Oscar states
• Masters degree or advanced certificate
• Prior experience with Utilization management

Benefits

• medical, dental, and vision benefits
• 11 paid holidays
• paid sick time
• paid parental leave
• 401(k) plan participation
• life and disability insurance
• paid wellness time and reimbursements
• unlimited vacation program
• annual performance bonuses

Before you apply

• Willing to obtain additional state licensure (with Oscar's support)

About the company

Oscar is a health insurance company built around a full stack technology platform. It was started in 2012 to create a health insurance company that behaves like a doctor in the family.