Associate Director, Appeals & Grievances

The role

The Associate Director provides strategic leadership and operational oversight for non-clinical Administrative Grievances and Appeals and Elite Member Champion Team operations. This role drives operational excellence and regulatory compliance using Lean methodologies and capacity-based staffing models.

What you will do

• Lead operational goals for CGA and Escalation teams
• Develop a multi-tiered team of managers, lead, and specialists
• Act as resolution authority for high-visibility, high-risk administrative complaints
• Establish and enforce standardized evaluation, escalation, and resolution workflows
• Maintain constant audit readiness for CMS, state DOI, and internal compliance audits
• Partner with Claims, Network, Legal, and Compliance teams to implement root-cause solutions
• Maximize operational efficiency using workforce data and Lean methodologies
• Manage delegated vendor entities to ensure adherence to standards
• Present performance metrics and strategic recommendations to executive leadership
• Comply with all applicable laws and regulations

Required qualifications

• 7+ years of progressive experience in healthcare operations, specifically focusing on healthcare compliance, complaints, grievances, or appeals (A&G)
• 4+ years of people management experience, including leading and developing other supervisors, team leads, or managers in a high-volume operations environment
• Advanced knowledge and equivalent experience with Commercial Insurance, Medicare/Medicaid, and Affordable Care Act (ACA) rules and regulations relating to administrative Grievance & Appeals processes
• Experience leading or representing operational teams during CMS, state-level, or other regulatory audits
• Experience using operational data to lead decision-making, manage capacity, and implement process improvements

Nice to have

• Bachelor's Degree or 4 years of equivalent experience
• Operational Excellence Certification (Lean Six Sigma Green/Black Belt or equivalent)
• Experience leading remote or multi-site teams in a collaborative, fast-paced environment
• Experience with data visualization tools (Tableau, Looker) and specialized case management systems (such as Inovaare or Jira)
• Advanced Degree (MBA, Master of Health Administration, or Juris Doctor)

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

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.