Utilization review nurse [h1.location_city]

Job Description

Job Description

Hi, we're Oscar. We're hiring a Senior UM Review Nurse to join our Utilization Review 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 :

You will leverage clinical knowledge, judgment, and established criteria to determine the medical appropriateness of healthcare services. Senior nurses work as individual contributors completing reviews, and act as subject matter experts (SME). You will interact regularly with peers, Oscar medical providers, and other internal teams to successfully fulfill their role.

You will report into the UM Nurse Manager.

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; Oklahoma; Pennsylvania; South Carolina; Tennessee; Texas; or Virginia. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events.#LI-Remote

Pay Transparency : The base pay for this role is : $40.21 - $52.77 per hour. You are also eligible for employee benefits and monthly vacation accrual at a rate of 15 days per year.

Responsibilities :

• Gather relevant medical information (via internal resources, ticket, and document review) and complete medical necessity and level of care reviews using clinical judgment and the Plan's clinical guidelines
• Meet required decision-making timeframes, including promptly triggering escalations requiring physician review
• Write clear and concise reviews of inpatient & lower level of care admissions, as well as outpatient and specialty service requests
• Comply with department performance and quality metrics, and adhere to training and remediation requirements
• Support nurse supervisor & managers in daily queue oversight including identifying and flagging clinical trends / issues
• Effectively use Oscar tools to investigate and perform utilization reviews, and to support queue oversight and staffing
• Acts as a clinical resource and escalation point for peers, assists in precepting of newly hired nurse reviewers, and serve as continual champions of the Oscar mission
• Contribute to root cause analysis and process improvement initiatives
• Use working knowledge and familiarity with applicable utilization management regulatory and accreditation requirements on a day to day basis to ensure accurate reviews
• Act as subject matter experts and support the supervisory team in that capacity
• Compliance with all applicable laws and regulations
• Other duties as assigned

Requirements :

Bonus points :

This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here.

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.

Pay Transparency : Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including : medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements.

Artificial Intelligence (AI) : Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts.

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.

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