Utilization Review Nurse

Oscar Health; United States; Remote; USD 48,000 - 62,000; Full time

Benefits offered by this job

15 days vacation per year

Benefits package

Remote work flexibility

Job summary

Oscar Health is seeking a Utilization Review Nurse to join our team. You will review cases, verify medical records, and consult with care providers to assess treatment appropriateness using Oscar Clinical Guidelines, MCG, and InterQual.

The role reports to the Supervisor, Utilization Review. This remote position is open to multiple states with occasional travel for meetings and events. The base pay ranges from $35.00 to $45.94 per hour, plus benefits and vacation accrual.

Qualifications

• Active, unrestricted RN licensure in the US or compact multistate license.
• Associate degree in nursing or nursing diploma; BSN preferred.
• Ability to obtain additional state licenses as needed.
• 1+ year of utilization review experience in managed care.
• Experience with MCG or InterQual guidelines.
• 1+ year clinical practice in acute care (ER or hospital).
• Weekend availability required; at least one weekend day per week.

Responsibilities

• Perform medical necessity and level of care reviews.
• Gather necessary information via phone and fax to assess clinical conditions.
• Apply evidence-based guidelines to determine care appropriateness.
• Meet required decision-making SLAs and refer for further engagement when needed.
• Ensure compliance with applicable laws and regulations.

Skills

RN license

Utilization review

MCG familiarity

InterQual familiarity

Clinical experience

Weekend availability

Education

RN license (US)

Associate degree in nursing or nursing diploma

BSN

Tools

Milliman Care Guidelines

InterQual

Job description

Hi, we're Oscar. We're hiring a Utilization Review Nurse to join our Utilization Review team.

About the role:

You will perform frequent case reviews, check medical records and speak with care providers regarding treatment as needed. You will make recommendations regarding the appropriateness of care for identified diagnoses based on the research results for those conditions.

You will report into the Supervisor, Utilization Review.

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 is: $35.00 - $45.94 per hour. You are also eligible for employee benefits and monthly vacation accrual at a rate of 15 days per year.

Responsibilities:

• Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and Oscar Clinical Guidelines, Milliman Care Guidelines
• Obtain the information necessary (via telephone and fax) to assess a member's clinical condition, and apply the appropriate evidence-based guidelines
• Meet required decision-making SLAs
• Refer members for further care engagement when needed
• Compliance with all applicable laws and regulations
• Other duties as assigned

Requirements:

• Active, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
• Associate Degree - Nursing or Graduate of Accredited School of Nursing Or Successful completion of Nursing Diploma Program in Accredited School of Nursing
• Ability to obtain additional state licenses to meet business needs
• 1+ year of utilization review experience in a managed care setting
• Strong experience utilizating MCG (Milliman Care Gudielines) or InterQual
• 1+ years of clinical experience (including at least 1+ year clinical practice in an acute care setting, i.e., ER or hospital)
• Weekend availability is required; all applicants must be able to work at least one weekend day (Saturday or Sunday) each week.
• BSN
• Previous experience conducting concurrent or inpatient reviews for a managed care plan

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.

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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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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.

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