Utilization Review Nurse Ma (Remote)
Posted on 6/2/2022
- Active, unrestricted RN license
- Willingness to obtain additional state licenses as needed for Oscar's growth (with Oscar's support)
- 3+ years utilization review experience at a managed care plan or provider organization
- 5+ years clinical experience (including at least 2 years clinical practice in an acute care setting, i.e., ER or hospital)
- Collect relevant medical information (via telephone and fax) and apply the appropriate evidence-based guidelines and medical policies to determine medical necessity which could include CMS guidelines (NCDs and LCDs) Oscar Clinical Guidelines, Milliman Care Guidelines, Hayes, UpToDate, etc
- Meet required decision-making timeframes, including promptly triggering escalation for cases requiring physician review
- Follow documentation guidelines for clear and concise decision-making within our utilization review tracking platform
- Use Oscar tools and processes to perform and properly track all utilization reviews
- Appropriately refer members for further care engagement when needed
- Develop a working familiarity with applicable regulatory and accreditation requirements
- Participate in quality improvement activities as requested
- Clear written and spoken communication, including a poised phone presence
- Maintain continued active licensures, professional growth, and education to meet continuing education requirements and demonstrate knowledge & understanding of current nursing care practice
- Experience with Medicare Advantage plans
- Able to multi-task and manage tasks to completion on a timely basis and in an organized fashion
- Familiar with google platforms; willing and able to learn new software tools
- Able to work in a fast paced and evolving environment such as a startup
Health insurance company
Oscar Health’s mission is to make high-quality health insurance accessible and affordable for everyone. The company is a software driven health insurance company that offers medical plans, medicare advantages, and small group products.
- Health insurance - That’s a given. Employees and their families receive incredible health insurance.
- Financial benefits - A penny saved....we’re talking about a 401K plan, health savings accounts, and more.
- Well @ Oscar - We care about your wellness with fitness classes and access to mental health support.
- Work-Life Balance - We offer multiple time-off options, wellness days, and 10+ weeks of parental leave.
- Learning & Development - We offer everything from mentorship to management training.
- What we do is a big deal. We’re solving problems that change and save lives.
- Powered by people. Members above all. Developing and growing others is what raises the bar.
- No genius without grit. Be relentless. Be scrappy. Trying and failing beats not trying and changing nothing.
- Seek the truth... but never assume you’ve found it. Be scientific.
- Inspire & provoke. Develop and display leadership at all levels. Fight to be the best.
- Be transparent. Give and ask for direct feedback. Be grateful for and excited by the help of others.
- Make it right. Admit your mistakes. Then learn from them. Never build alone.