Utilization/Clinical Review Nurse - Medicare Advantage

Oscar, Texas, Arizona

A better kind of health insurance company

Utilization/Clinical Review Nurse (Medicare Advantage) 

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're looking for experienced clinicians to join the fast-growing Utilization Management/Clinical Review team. We're 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 a Utilization/Clinical Review Nurse for our Medicare Advantage product, you will determine the medical appropriateness of inpatient and outpatient services by reviewing clinical information and applying CMS and established evidence-based guidelines. You will also interact with Oscar providers, members, and internal service team to obtain necessary information and communicate approval determinations.

Your primary responsibility in this role will be to conduct initial assessments of medical necessity for inpatient and outpatient services. In order to do so, you will need to:

  • Collect relevant medical information (via telephone and fax) and apply the appropriate CMS guidelines (NCDs and LCDs), evidence-based guidelines and medical policy
  • Meet required decision-making timeframes, including promptly triggering escalation for cases requiring physician review
  • Clearly document all communication and decision-making within our utilization review tracking platform, ensuring a peer could easily reference and understand your decision
  • Demonstrate the highest level of professionalism, accountability, and service in your interactions with Oscar teammates, customer service, providers, and members
  • Learn and use Oscar tools and processes to perform and properly track all utilization reviews, as well to refer members for further care engagement when needed
  • Develop a working familiarity with applicable regulatory and accreditation requirements  
  • Participate in quality improvement activities as requested
  • Provide feedback into improving Oscar's overall operations and member/provider experience
  • Maintain continued professional growth and education to meet continuing education requirements and demonstrate knowledge & understanding of current nursing care practice

Required experience and qualifications include:


  • Active, unrestricted RN or LVN (BSN preferred) license 
  • Willingness to obtain additional state licenses as needed for Oscar's growth (with Oscar's support)
  • Experience of at least:
  • Three years utilization review experience at a medicare/medicare advantage care plan and
  • Five years healthcare experience (including at least 2 years clinical practice in an acute care setting, i.e., ER or hospital)
  • 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, including a poised phone presence
  • Flexible mindset: we are a fast-moving and evolving startup

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.

About Oscar

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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