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Utilization Review Nurse Ma (Remote)
Posted on 6/2/2022
INACTIVE
Locations
Arizona, USA
Experience Level
Entry
Junior
Mid
Senior
Expert
Requirements
  • 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)
Responsibilities
  • 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
Desired Qualifications
  • BSN
  • 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
Oscar Health

1,001-5,000 employees

Health insurance company
Company Overview
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.
Benefits
  • 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.
Company Values
  • 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.