Utilization Review Nurse
Hi, we're Oscar. We're hiring a Utilization Review Nurse to join our Clinical Review team.
Oscar is the first health insurance company built around a full stack technology platform and a 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 a Utilization/Clinical Review Nurse, you will determine the medical appropriateness of inpatient and/or Outpatient services by reviewing clinical information and applying evidence-based guidelines. You will also interact with Oscar providers, members, and internal service team to obtain necessary information and communicate approval determinations.
You will report to the Clinical Review Nurse Supervisor
This is a remote / work-from-home role. You must reside in one of the following states: Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Iowa, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change. #LI-Remote
The base pay for this role is: $72,703 - $94,596 per year. You are also eligible for employee benefits, and monthly vacation accrual up to 10 days per year.
- Responsible for utilization management and utilization review for prospective (prior authorization) reviews.
- Perform reviews of services, and determine medical appropriateness outpatient services following evaluation of medical guidelines and benefit determination.
- RN will obtain the information necessary (via telephone and fax) to assess a member's clinical condition, and apply the appropriate evidence-based guidelines and medical policies to determine medical necessity which could include 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
- Participate in special projects related to utilization management as needed
- Maintain continued active licensures and education to meet continuing education requirements and demonstrate knowledge & understanding of current nursing care practice
- Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multi-state unrestricted RN license as defined by the Nurse Licensure Compact NLC).
- Associate Degree - Nursing or Graduate of Accredited School of Nursing
- Must obtain additional state licenses as needed for Oscar's growth (with Oscar's support)
- One year of utilization review experience in a managed care setting
- Two or more years clinical experience (including at least 1 year in a clinical practice in an acute care setting, i.e., ER or hospital)
- Experience with medical decision support tools (i.e. Interqual, MCG, NCCN)
- Knowledge of Medicaid, Commercial or Medicare Managed Care programs and regulations
- Three or more years utilization review experience at a managed care plan or provider organization
- Familiar with google platforms; willing and able to learn new software tools
- Computer skills to include Google Docs, Google Sheets,
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..
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.
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 (email@example.com) to make the need for an accommodation known.
Something looks off?