Utilization Review Nurse at Oscar Health

**Who this is for** Oscar Health is seeking a dedicated Utilization Review Nurse to join their remote Utilization Review team. This role is ideal for experience

Work type: remote

Location: Remote

Salary: $35 – $46/hr

Type: Full-time

Summary

**Who this is for** Oscar Health is seeking a dedicated Utilization Review Nurse to join their remote Utilization Review team. This role is ideal for experienced RNs who are passionate about ensuring appropriate patient care and managing medical necessity reviews. **Key highlights** This fully remote position offers the opportunity to impact member care by conducting thorough case reviews and collaborating with care providers. You'll utilize clinical judgment and established guidelines to make crucial recommendations for treatment appropriateness. **You might be a good fit if you...** - Hold an active, unrestricted RN license in Texas, Georgia, Arizona, or Florida, or a compact multistate license. - Possess at least 1 year of utilization review experience in a managed care setting and 1+ year of clinical experience, including acute care. - Have experience with MCG or InterQual tooling and can apply evidence-based guidelines effectively. - Are comfortable communicating via telephone and fax to gather necessary clinical information.

Job Description

Hi, we're Oscar. We're hiring a Utilization 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 perform frequent case reviews, check medical records and speak with care providers regarding treatment as needed. You will make recommendations regarding the appropriateness of care for identified diagnoses based on the research results for those conditions.

You will report into the Supervisor, Utilization Review.

Work Location:This is a remote position, open to candidates who reside in: Texas, Georgia, Arizona, and Florida. 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: $35.00 - $45.94 per hour. You are also eligible for employee benefits and monthly vacation accrual at a rate of 15 days per year.

Responsibilities:

• Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and Oscar Clinical Guidelines, Milliman Care Guidelines

• Obtain the information necessary (via telephone and fax) to assess a member's clinical condition, and apply the appropriate evidence-based guidelines

• Meet required decision-making SLAs

• Refer members for further care engagement when needed

• Compliance with all applicable laws and regulations

• Other duties as assigned

• Active, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)

• Associate Degree or Bachelors Degree - Nursing or Graduate of Accredited School of Nursing

• MCG or InterQual tooling experience

• Ability to obtain additional state licenses to meet business needs

• 1+ year of utilization review experience in a managed care setting

• 1+ years of clinical experience (including at least 1+ year clinical practice in an acute care setting, i.e., ER or hospital)

• BSN

• Previous experience conducting concurrent or inpatient reviews for a managed care plan

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.

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