[Hiring] Associate Director, Appeals & Grievances @Oscar Health

Role Description

The Associate Director, Escalations — Administrative Complaints, Grievances & Appeals (CGA) provides strategic leadership and operational oversight for Oscar's non-clinical Administrative CGA and Elite Member Champion Team (MCT) operations. This role is responsible for driving operational excellence and regulatory compliance across all lines of business, and utilizes Lean methodologies and capacity-based staffing models to maintain strict adherence to federal (CMS) and state turnaround times. The Associate Director, Escalations — Administrative CGA will lead high-performing teams through complex administrative member and provider issue resolutions, leverage case data to mitigate reputational risk, and collaborate with cross-functional partners in Claims, Network, Legal, and Compliance to eliminate root causes and proactively reduce overall escalation volume while fostering a strong talent pipeline.

You will report into the Senior Director Member & Provider Programs.

Work Location: This is a remote position, open to candidates who reside in:

• Arizona
• Florida
• Georgia
• Illinois
• Iowa
• Kansas
• Michigan
• Missouri
• Nebraska
• New Jersey
• North Carolina
• Ohio
• California
• Pennsylvania
• South Carolina
• Tennessee
• Texas
• Virginia

Pay Transparency: The base pay for this role in the states of California, Connecticut, New Jersey, New York, and Washington is: $123,372.00 - $161,925.75 per year. The base pay for this role in all other locations is: $111,034.80 - $145,733.18 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program and annual performance bonuses.

Responsibilities

• Lead operational goals for CGA and Escalation teams, maintaining full accountability for compliance and quality metrics across all lines of business.
• Develop a multi-tiered team of managers, lead, and specialists using structured coaching frameworks and clear performance accountability to foster high engagement.
• Be the ultimate resolution authority for high-visibility, high-risk administrative complaints coming from senior leadership, regulatory bodies, and social channels.
• Establish and enforce standardized evaluation, escalation, and resolution workflows to ensure seamless end-to-end case ownership and eliminate friction.
• Maintain constant audit readiness and act as the primary operational lead for CMS, state Department of Insurance (DOI), and internal compliance audits.
• Partner with Claims, Network, Legal, and Compliance teams to turn case data insights into systemic root-cause solutions.
• Maximize operational efficiency and cost-effectiveness by using workforce data, capacity staffing models, and Lean methodologies.
• Manage delegated vendor entities to ensure full adherence to contractual, regulatory, and quality CGA standards.
• Present performance metrics, operational trends, and strategic compliance recommendations to executive leadership.
• Compliance with all applicable laws and regulations.
• Other responsibilities as assigned.

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.

Requirements

• Bonus points:
• 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