Physician Reviewer - Utilization Management

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: $211,200 - $ 277,200 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation, and 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).
• 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
• This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here .
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Benefits

Additional Information

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.

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