Senior Clinical Quality Nurse

Oscar-Health-; Dallas (TX); Remote; USD 75,000 - 99,000; Full time

Benefits offered by this job

Medical, dental, vision benefits

11 paid holidays

Paid sick time

401(k) plan participation

Life and disability insurance

Paid wellness time and reimbursements

Job summary

Oscar Health seeks a Senior Clinical Quality Nurse to drive clinical performance through audits and care reviews. You will mentor colleagues and implement audit programs aligned with departmental goals and regulatory requirements. This remote role reports to the Nurse Supervisor, UM Clinical Quality.

Ideal candidates hold an active RN license, 2+ years of nursing and utilisation review experience, and have NCQA/HEDIS knowledge. Strong data skills and Google Workspace proficiency are a plus.

Qualifications

• Licensed RN with active license in state of residence + willingness to obtain additional licenses
• 2+ years as a Registered Nurse
• 2+ years experience in a clinical care setting
• 1+ years of utilization review experience in a managed care context
• Experience auditing medical records and health plan data for quality
• Knowledge of NCQA accreditation standards (utilization management/case management/ population health)
• Experience with data analysis and reporting for quality performance

Responsibilities

• Perform quality audits on clinical documentation from multiple clinical departments
• Develop audit surveys and rubrics to ensure transparent audit requirements
• Pull and track clinician/provider cases for auditing and reporting
• Support NCQA and regulatory audit readiness
• Provide feedback and coaching to staff on audit requirements and quality practices
• Collaborate with leadership to present audit trends and action plans
• Deliver quality-focused presentations and report performance trends to stakeholders
• Participate in calibration sessions to ensure audit consistency
• Support interrater reliability processes as needed

Skills

RN license

Utilization review

NCQA/HEDIS knowledge

Healthcare quality assurance

Data interpretation

Google Workspace

Communication skills

Collaborative teamwork

Education

BSN preferred

Tools

Google Sheets

Google Docs

Google Slides

Google Meet

Job description

Hi, we're Oscar. We are hiring a Senior Clinical Quality nurse to join our 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

Clinical Quality programs are designed to enhance clinical outcomes and concierge-level service to our members, through review of services provided to members from network healthcare providers, facilities and Oscar employees. The Senior Clinical Quality Nurse drives clinical performance through the quality auditing and clinical quality of care review process for the departments they serve. The Clinical Quality Nurse serves as a peer mentor and a consultant, working collaboratively with team members to implement audit programs that reflect departmental goals and measurements, meeting all regulatory and organizational requirements.

You will report into the Nurse Supervisor, UM Clinical Quality.

Work Location

This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; Illinois; Iowa; Kansas; Michigan; Missouri; Nebraska; New Jersey; North Carolina; Ohio; Pennsylvania; South Carolina; Tennessee; Texas; or Virginia. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events.

Pay Transparency

The base pay for this role in the states of California, Connecticut, New Jersey, New York, and Washington is: $83,628 - $109,761 per year. The base pay for this role in all other locations is: $75,265 - $98,785 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program and annual performance bonuses.

Responsibilities

• Perform quality audits on clinical documentation for clinicians from a variety of clinical departments.
• Develop audit surveys and rubrics to ensure the transparency of audit requirements, supporting evidence-based clinical decision making and adherence to department workflows and align with regulatory accreditation requirements.
• Pull clinician and provider cases for auditing purposes, tracking results in department systems and tracking mechanisms.
• Support organizational readiness and preparation for NCQA and other regulatory audits.
• Perform delegate oversight audits, writing audit result summary reports and presenting to stakeholders and delegates. Collaborate with leadership to develop corrective action plans to address identified gaps.
• Provide 1:1 feedback and coaching to front-line staff and leaders regarding departmental workflows and audit requirements and support developing training tools on quality best practices, audit standards and other topics as directed.
• Support developing training tools on quality best practices, audit standards and other topics as directed.
• Collaborate with leadership/stakeholders on audit trends, process changes, training development. Deliver quality-oriented presentations and aggregate quality data to report performance trends to stakeholders.
• Participate in audit calibration sessions with internal staff and stakeholders to ensure audit consistency.
• Participate in the interrater reliability process (IRR) as needed to support consistent clinical decision making across teams.
• Compliance with all applicable laws and regulations.
• Other duties as assigned.

Requirements

• Licensed Registered Nurse with active, unrestricted license in state of residence and willingness to obtain additional licenses as needed for Oscar’s growth (with Oscar’s support)
• 2+ years of experience as a Registered Nurse
• 2+ years experience working in a clinical care setting
• 1+ years of utilization review experience at a managed care plan or provider organization
• Experience in healthcare quality assurance, including experience auditing medical records and evaluating clinical information and internal documentation to determine the quality of care and service provided to members.
• Experience in health plan case management.
• Bachelor’s Degree from an accredited university, BSN Preferred.
• A working knowledge of health insurance/benefit concepts - Medicare and Individual Marketplace insurance experience a plus.
• Strong understanding of NCQA accreditation standards for utilization management, case management or population health, HEDIS measures and other regulatory requirements.
• CCM or MCG certification.
• Experience analyzing and interpreting performance and other forms of data.
• Proficiency using Google applications like Sheets, Docs, Slides and Meets.
• Comfortable using Google Meets and other platforms to communicate with internal/external stakeholders.

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.

California Residents

For information about our collection, use, and disclosure of applicants’ personal information as well as applicants’ rights over their personal information, please see our Privacy Policy .

Oscar Health is authorized to do business in many, but not all, states. If you are not located in or willing to relocate to a state where Oscar is registered, you will not be eligible for employment. The approved states for this role are listed in the job posting.