Physician Reviewer - Utilization Management

Oscar Health; United States; On-site; USD 219,000 - 287,000; Full time

Benefits offered by this job

Medical, dental, and vision benefits

11 paid holidays

401(k) plan participation

Life and disability insurance

Wellness time and reimbursements

Job summary

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

This remote role in the United States offers work from home with occasional travel for meetings. Base pay ranges from $219,000 to $286,902 per year, plus benefits and performance bonuses.

Qualifications

• Board-certified MD or DO required.
• Licensed in FL, NC, AZ or hold active Interstate Medical Licensure Compact (IMLC).
• Minimum 6+ years of clinical practice.

Responsibilities

• Determine medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines.
• Provide clinical determinations based on internal guidelines and evidence-based criteria.
• Document all communication and decisions clearly in Oscar workflow tools for traceability and readability.

Skills

Medical review

Evidence-based guidelines

Clinical documentation

Communication

Education

Board-certified MD/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: $219,000- $ 286,902 per year.

• You are also eligible for employee benefits, participation in Oscar's unlimited vacation, and annual performance bonuses.

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.

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

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.

Artificial Intelligence (AI):

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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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