Clinical Regulatory Specialist Details

Clinical Regulatory Specialist

Oscar Health - Arizona

Employment Type : Full-Time

Hi, we're Oscar. We're hiring a Clinical Regulatory Specialist to join our Clinical Training and Quality team.

Oscar is the first health insurance company built around a full stack technology platform and a relentless 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:

As an RN on the Clinical Quality team, you will be responsible for ensuring that our case management programs and delegates are compliant with organizational, federal and state regulatory requirements. Your work will have a direct impact on the success of our departmental programs along with delegate compliance and performance, and for Oscar as a whole. You will report to Director of Clinical Quality and Training.

This is a remote / work-from-home role. You must reside in one of the following states: Arizona, California, Connecticut, Florida, Georgia, Illinois, Maryland, Massachusetts, Michigan, New Jersey, New Mexico, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Virginia, or Washington. Note, this list of states is subject to change.

Responsibilities:

• Learn, and stay updated on current NCQA, regulatory and organizational requirements and train staff and leadership in how to comply with these requirements.
• Lead regulatory oversight for the Clinical Care Team - maintain continuous organizational readiness for NCQA, regulatory and external client audits through coordination of and participation in onsite/virtual audit surveys.
• Work collaboratively with Oscar Compliance, Delegate Oversight and Quality Improvement departments to maintain organizational compliance and coordinate audit activities.
• Audit clinician documentation for compliance with regulatory requirements; identify trends and develop action plans in collaboration with staff and department leaders to mitigate identified risks.
• Work with internal stakeholders to ensure department compliance with state and federal regulations and coordinate delegate information needed for external regulatory audits (e.g., CMS program audits, state regulatory audits, etc)
• Conduct pre and post-delegation audits of CM/CCM delegates against federal and state regulatory requirements working with internal delegate account managers to remediate any findings identified.
• Continuously monitor department and delegate performance to ensure compliance with regulatory requirements and internal standards.
• Draft, coordinate approval, and update department and program P&P's in partnership with legal and compliance.
• Analyze organizational performance data and create written documents for presentation work in provider Joint Oversight Committees and organizational subcommittee meetings.
• Write and coordinate implementation of corrective action plans post audits to address identified issues.
• Consult with CCT leadership re: compliance considerations when developing/changing department workflows and documentation.
• Other duties as assigned

Requirements:

• Bachelor's Degree from an accredited university or equivalent experience
• Active and unrestricted nursing license in state of residence
• 2+ years of work experience in some or all of the following:
• Experience writing program descriptions, processes, procedures, or policy documents
• Experience in presenting clinical and regulatory compliance information to large committees in virtual settings (videoconferencing)
• Computer/tech-savvy- intermediate or advanced skill level in the development and use of spreadsheets, power points, word documents - able to work in multiple systems concurrently

Bonus points:

• Experience working with health insurance organizations to maintain compliance with NCQA, Medicare, Medicaid and other regulatory requirements for health insurers.
• Master's degree, CCM or CPHQ certification
• Experience in presenting to executive leadership

Life at Oscar:

At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care - an experience made whole by our unique backgrounds and perspectives.

We aim to make health care affordable and accessible for all, and apply this same vision to our perks and benefits, including: medical benefits, generous paid-time off, paid parental leave, retirement plans, company social events, stocked kitchens, wellness programs, and volunteer opportunities.

Reasonable Accommodation:

Oscar applicants are considered solely based on their qualifications, without regard to applicant's disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known.

Pay Transparency Policy:

Oscar ensures that you won't be discharged or discriminated against based on whether you've inquired about, discussed, or disclosed your pay. Read the full policy here.

COVID-19 vaccine requirements for in-person work:

To protect the health and safety of our employees, we require any employee conducting in-person work* to be fully vaccinated against COVID-19 by their start date. If you are unable to be vaccinated due to medical or protected religious reasons, please reach out to our Benefits team at accommodations@hioscar.com to submit an accommodations request.

• Note: In-person work includes: employees required to work from our offices (either full-time or part-time), employees conducting sales work in the field and employees conducting at-home or in-person visits with members.

Life at Oscar:

At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care - an experience made whole by our unique backgrounds and perspectives.

We aim to make health care affordable and accessible for all, and apply this same vision to our perks and benefits, including: medical benefits, generous paid-time off, paid parental leave, retirement plans, company social events, stocked kitchens, wellness programs, and volunteer opportunities.

Reasonable Accommodation:

Oscar applicants are considered solely based on their qualifications, without regard to applicant's disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known.

Pay Transparency Policy:

Oscar ensures that you won't be discharged or discriminated against based on whether you've inquired about, discussed, or disclosed your pay. Read the full policy here.

COVID-19 vaccine requirements for in-person work:

To protect the health and safety of our employees, we require any employee conducting in-person work* to be fully vaccinated against COVID-19 by their start date. If you are unable to be vaccinated due to medical or protected religious reasons, please reach out to our Benefits team at accommodations@hioscar.com to submit an accommodations request.

• Note: In-person work includes: employees required to work from our offices, employees conducting sales work in the field and employees conducting at-home or in-person visits with members.