Associate Medical Director, Utilization Management

About the role

This role determines the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines. This role also influences departmental strategy, leading and overseeing a team of physicians ensuring efficient management and adherence to quality standards. You will report into the Senior Medical Director. Work Location: This is a remote position, open to candidates holding an active medical license in Florida, Arizona or North Carolina, OR to physicians who hold an IMLC compact license. 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: $240,120 - $315,157 annually. You are also eligible for employee benefits including a performance bonus, 401K with immediate vesting, and unlimited PTO.

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).
• Use correct templates for documenting decisions during case review.
• 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.
• Manage direct reports and oversee their performance.
• Provide oversight to ensure the team meets turn-around times for clinical reviews.
• Collaborate with other departments on Utilization Management Operations.
• Lead key projects and drive initiatives to successful completion.
• Other duties as assigned
• Compliance with all applicable laws and regulations.ocus on the main or important responsibilities))

Requirements

• Board certification as an MD or DO with a current unrestricted license to practice medicine is required.
• 3+ years of clinical practice
• 2+ years of utilization review experience in a managed care plan (health care industry)
• Bonus points:
• Licensure in multiple Oscar states
• Experience with care management within the health insurance industry.
• Willing and able to obtain additional state licensure as business needs, with Oscar's support
• This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here .
• 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.
• 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 .

Benefits

Additional Information

Hi, we're Oscar. We're hiring an Associate Medical Director 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.

Your Match

How well this role fits your profile.

Company Intel

What employees say

Worked at Oscar? Share your experience