Associate Medical Director, Regulatory Management

Oscar Health•Remote, FL

4d•$216,108 - $283,642•Remote

About The Position

The Associate Medical Director, Regulatory Management provides strategic and operational leadership for provider clinical regulatory programs and credentialing operations. The role drives clinical policy guidance, ensures enterprise compliance with NCQA, CMS, state, and accreditation standards, and leads continuous process improvement. Working cross-functionally with Quality, Network Management, and Compliance, this leader optimizes provider onboarding to deliver a high-quality, compliant network that supports member access and organizational growth. This is a fully remote position for candidates residing in eligible U.S. locations, excluding Alaska, Delaware, Hawaii, Louisiana, Montana, North Dakota, Oklahoma, West Virginia, Wyoming, and U.S. Territories. Work is completed from a home office, with occasional travel for team meetings and company events.

Requirements

7+ years of progressive healthcare experience, including leadership responsibility.
3+ years of experience managing provider credentialing within a health plan, managed care organization, or large healthcare system.
3+ years of knowledge of NCQA credentialing standards, CMS health plan regulatory requirements, and applicable federal and state regulations.
1+ years of 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 deliver measurable operational results.
MD or DO with a current unrestricted license to practice medicine.
Reviewers must maintain necessary credentials to retain the position, including active board certification.
Willingness to obtain additional state licensure, with Oscar's support.

Nice To Haves

Licensure in multiple Oscar states.
Master's degree or advanced certificate.
Prior experience with utilization management.

Responsibilities

Build and lead the Clinical Policy Compliance team and the Clinical Coding Center of Excellence, driving compliance, quality, and regulatory strategy across the organization.
Direct development of clinical regulatory policies, Benefit Interpretation Policies (BIPs), and operational SOPs to align with state and federal laws, in partnership with Office of Clinical Affairs subject-matter experts.
Chair the Credentialing, Peer Review, and Population Health Management sub-committee, lead individual case reviews, and report key performance metrics to quarterly Quality Improvement meetings.
Oversee practitioner and facility credentialing, ensuring compliance with NCQA standards, CMS requirements, and state regulations by verifying licenses, board certifications, and sanction histories.
Partner with Network and Market Management executives to accelerate provider onboarding and resolve network gaps while maintaining credentialing integrity.
Collaborate on Quality Improvement for Clinical Review Operations, optimizing Inter-Rater Reliability (IRR) processes, clinical delegate audits, and Potential Quality Issue (PQI) workflows.
Identify and resolve operational bottlenecks to streamline processes, eliminate delays, and enhance member and provider satisfaction without compromising quality or compliance.
Serve as a subject-matter expert on state and federal healthcare regulations; monitor legal developments and translate regulatory changes into operational updates to maintain compliance.
Comply with all applicable laws and regulations.
Perform other duties as assigned.