Remote Physician Reviewer - Utilization Management

Oscar Health; Polska; Hybrid; PLN 857,000 - 1,122,000; Full time

Benefits offered by this job

Unlimited vacation

Annual performance bonus

Medical, dental, and vision benefits

11 paid holidays

401(k) plan participation

Life and disability insurance

Paid wellness time

Job summary

Oscar Health is seeking a Physician Reviewer to join the Utilization Management team in a remote capacity in the United States. You will determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines.

The role reports to the Associate Medical Director, Utilization Management, and offers base pay with eligible benefits and bonuses. Hours are 8am-5pm in local time, with weekend rotation every 16 weeks.

Qualifications

• Board certification as an MD or DO
• Licensed in one of these states: FL, NC, AZ OR possess an active Interstate Medical Licensure Compact (IMLC).
• 6+ years of clinical practice
• Licensure in multiple Oscar states
• 1+ years of utilization review experience in a managed care plan
• BC in Cardiology, Radiation/Oncology, or Neurology
• Experience with care management within the health insurance industry
• Willing and able to obtain additional state licensure as needed, with Oscar's support

Responsibilities

• Provide 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).
• 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

Job description

Oscar Health is seeking a Physician Reviewer to join the Utilization Management team in a remote capacity in the United States. You will determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines.

The role reports to the Associate Medical Director, Utilization Management, and offers base pay with eligible benefits and bonuses. Hours are 8am-5pm in local time, with weekend rotation every 16 weeks.