At Oscar, we work hard to provide the kind of health insurance we would want for ourselves. This means that we get to be creative and to build an excellent health insurer from the ground up. We are looking for an experienced physician to support Oscar’s fast-growing Utilization Management team. Specifically, we are looking for a physician that is experienced in Medicare medical management. We are working to bring a new level of service to utilization review and ensure Oscar members receive access to appropriate care in a timely, transparent way.
As one of Oscar’s Medical Directors for Utilization Management, you will be one of the primary physician reviewers who determines the medical appropriateness of inpatient, outpatient and pharmacy services by reviewing clinical information and applying evidence-based guidelines. You will be a critical part of our clinical review team, including non-clinician processors, nurses and part-time physicians.
You will report to the Senior Medical Director for Utilization Management. In this role, you will interact with Oscar providers and members, in addition to other parts of our medical operations team, including state medical directors, operational leads, and quality and pharmacy subject matter experts. You will support projects aimed at strengthening our utilization review function and team. This is a full-time role that can be remote but geographically close to an Oscar market office.
Your primary responsibility in this role will be to provide timely medical reviews that meet our stringent quality parameters, drive clinical improvement, and educate and lead the clinical staff and part-time physician reviewers. More specifically, you will need to:
- Provide clinical determinations for Medicare and Commercial members based on evidence-based criteria including CMS guidelines and Oscar internal guidelines and policies, and other available guidelines and resources, while utilizing your 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 (either initial denial or internal / first level appeal).
- 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.
- Develop a working familiarity with applicable regulatory and accreditation requirements (especially CMS) as well as Oscar tools and workflows in place to ensure we meet them.
- Demonstrate the highest level of professionalism, accountability, and service in your interactions with Oscar teammates, providers, and members.
Clinician Team Leadership
- Develop clinical protocols and policies to enhance the quality of medical necessity decision-making, incorporating input from the clinical review team, operations, and other medical operations leads (state medical directors, quality, pharmacy)
- Support reporting and regulatory needs for the utilization review function for quality and regulatory purposes as necessary
- Participate in quality improvement activities as requested, e.g., QA and training in interrater reliability
- Support projects specific to building the team's clinical expertise and efficiency
- Support the Senior Medical Director for Utilization Management on operational improvements and member/provider experience involving clinical review tasks
Experience and qualifications include:
- Licensure: Board certification as an MD or DO with a current unrestricted license to practice medicine is required. Licensure in multiple Oscar states (CA, AZ, TX, MI, OH, TN, NJ, NY, FL) preferred but not required; you should be willing to obtain additional state licenses, with Oscar's support. Reviewers must maintain necessary credentials to retain the position.
○ 3+ years of clinical practice in one of the following fields: internal medicine, family medicine, general surgery, emergency medicine
○ 3+ years of utilization review experience in a managed care plan (health care industry)
○ Experience with Medicare clinical reviews, CMS criteria as well as familiarity with CMS policies and procedures around same
○ Experience with care management within the health insurance industry
○ Experience with medical record auditing and case review auditing
○ Experience with CMS audits
○ Experience with medical policy and criteria/medical development and writing
- Professional skills:
○ Able to multi-task and manage tasks to completion on a timely basis and in an organized fashion
○ Comfortable with technology; willing and able to learn new software tools
○ Clear written and spoken communication
○ Flexible mindset: we are a fast-moving and evolving company
At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we work to cultivate an environment where exceptional people can be their most authentic selves and find both belonging and support. We're on a mission to change healthcare -- an experience made whole by your unique background and perspectives.
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 ([email protected]) to make the need for an accommodation known.
Pay Transparency Policy: Oscar's Pay Transparency Policy ensures that you won't be discharged or discriminated against based on whether you've inquired about, discussed, or disclosed your pay. Read the full policy here.
Founded in 2012, Oscar is probably the last thing you would expect from a technology startup – a seemingly old-fashioned healthcare insurance provider. The company provides clients with the kind of clarity and simplicity we have come to expect from an e-commerce site. And, of course, they're hiring.
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