Physician Reviewer, Utilization Management

Hi, we're Oscar. We're hiring a Physician Reviewer to join our Utilization Management 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

This role determines the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines.

You will report to the Medical Director, Utilization Management.

Work Location: 

Oscar is a blended work culture where everyone, regardless of work type or location, feels connected to their teammates, our culture and our mission. 

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If you live within commutable distance to our New York City office (in Hudson Square), our Tempe office (off the 101 at University Dr), or our Los Angeles office (in Marina Del Rey), you will be expected to come into the office at least two days each week. Otherwise, this is a remote / work-from-home role.  

You must reside in one of the following states: Alabama, Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change. #LI-Remote

Pay Transparency:

The base pay for this role is: $211,200 - $277,200 per year. You are also eligible for employee benefits, participation in Oscar’s unlimited vacation program and annual performance bonuses.

Responsibilities

• Provide timely medical reviews that meet Oscar’s stringent quality parameters. 
• Provide clinical determinations based on evidence-based criteria and Oscar internal guidelines and policies, while utilizing clinical acumen.
• Clearly and accurately document all communication and decision-making in Oscar workflow tools, ensuring a member could easily reference and understand your decision (Flesch-Kincaid grade level).
• Use correct templates for documenting decisions during case review.
• Meet the appropriate turn-around times for clinical reviews.
• Receive and review escalated reviews.
• Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research.
• Compliance with all applicable laws and regulations 
• Other duties as assigned 

Qualifications

• Board certification as an MD or DO with a current unrestricted license to practice medicine is required
• 6+ years of clinical practice
• 1+ years of utilization review experience in a managed care plan (health care industry)

Bonus Points

• Licensure in multiple Oscar states
• Board Certified in Cardiology or Neurology
• Experience with care management within the health insurance industry
• Willing and able to obtain additional state licensure as business needs, with Oscar’s support