Physician Reviewer - Utilization Management

Oscar Health; New York (NY); Remote; USD 248,000 - 303,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

Paid holidays

Paid sick leave

Parental leave

401(k) plan

Life insurance

Disability insurance

Wellness time

Job summary

Oscar Health, Inc. is seeking a Physician Reviewer to join our Utilization Management team. You will assess medical necessity for hospital, outpatient, and pharmacy services based on evidence-based guidelines.

This remote role supports candidates in the United States. The base pay is $275,000 per year, with eligibility for benefits, unlimited vacation, and performance bonuses. You will report to the Associate Medical Director, Utilization Management.

Qualifications

• Board-certified medical doctor (MD) or DO.
• 6+ years of clinical practice.
• Licensed in one of the required states or eligible via IMLC.

Responsibilities

• Perform medical reviews to determine appropriateness of inpatient/outpatient/pharmacy services.
• Base determinations on evidence-based criteria and internal guidelines.
• Document decisions clearly in Oscar workflow tools with accessible notes.
• Use standard templates during case reviews.
• Meet turnaround times for clinical reviews.
• Review escalated cases promptly.
• Conduct peer-to-peer discussions with treating providers to clarify information.
• Comply with applicable laws and Oscar policies.

Skills

Board certification

Clinical experience

Education

MD or DO

Job description

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 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 determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence‑based guidelines.

Hours: 8am - 5pm in your local time zone

Call rotation - 1 weekend every 16 weeks

You will report into the Associate Medical Director, Utilization Management.

Work Location: This is a remote position, open to candidates who reside in the United States. 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: $275,000 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation, and annual performance bonuses.

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).
• 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

Requirements:

• 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

Bonus points:

• Licensure in multiple Oscar states
• 1+ years of utilization review experience in a managed care plan (health care industry)
• 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

This is an authentic Oscar Health job opportunity.

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.

Pay Transparency: 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.

Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts.

Reasonable Accommodation: 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 ([e-mail]) to make the need for an accommodation known.

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