Physician Reviewer - Utilization Management Clinical

Oscar Health Insurance; Northern (KY); Hybrid; USD 219,000 - 287,000; Full time

Benefits offered by this job

Medical, dental, and vision benefits

11 paid holidays

Paid sick time

Paid parental leave

401(k) plan participation

Life and disability insurance

Paid wellness time and reimbursements

Job summary

Oscar Health Insurance seeks an MD/DO to determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines.

This remote role (US-based) reports to the Associate Medical Director, Utilization Management, with travel for team meetings as needed. Base pay ranges from $219,000 to $286,902 per year, plus benefits.

Qualifications

• Board-certified MD or DO.
• Licensed in FL, NC, or AZ, or active IMLC license.
• 6+ years of clinical practice.
• Multiple Oscar state licensure.
• 1+ year of utilization review in managed care.
• Board certification in Cardiology, Radiation/Oncology, or Neurology.
• Willing to obtain additional state licensure with Oscar's support.

Responsibilities

• Provide timely medical reviews meeting Oscar's quality parameters.
• Provide clinical determinations based on evidence-based criteria and internal guidelines; use clinical acumen.
• Document all communications and decisions clearly in Oscar workflow tools for easy reference.
• Meet required turn-around times for clinical reviews.
• Receive and review escalated reviews.
• Conduct timely peer-to-peer discussions with treating providers to explain decisions and alternatives.
• Ensure compliance with applicable laws and regulations.
• Other duties as assigned.

Skills

Board certification

Medical license

Utilization review

Care management

Specialties: Cardiology

Specialties: Neurology

Interstate licensure

Experience with guidelines

Education

MD/DO

Job description

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.

• employee benefits
• participation in Oscar's unlimited vacation
• 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).
• 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
• 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.

Pay Transparency

Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience.

• medical, dental, and vision benefits
• 11 paid holidays
• paid sick time
• paid parental leave
• 401(k) plan participation
• life and disability insurance
• 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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