Utilization Review Nurse
Oscar Health
Job Overview
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Job Description
About Oscar Health
Oscar Health is the first health insurance company built around a full stack technology platform and a relentless focus on serving its members. Founded in 2012, Oscar aims to behave like a doctor in the family.
About The Role
As a Utilization Review Nurse at Oscar Health, 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 research and clinical guidelines.
You will report to the Supervisor, Utilization Review.
Work Location
This is a remote position open to candidates residing in Texas, Georgia, Arizona, and Florida. Daily work is performed from your home office with occasional travel for team meetings and company events.
Responsibilities
- Complete medical necessity and level of care reviews using clinical judgment and Oscar Clinical Guidelines.
- Obtain necessary information via telephone and fax to assess clinical conditions.
- Apply evidence-based guidelines and meet required decision-making SLAs.
- Refer members for further care engagement when needed.
- Ensure compliance with all applicable laws and regulations.
- Perform other duties as assigned.
Requirements
- Active, unrestricted RN licensure in the United States or compact multistate license.
- Associate or Bachelor’s Degree in Nursing or graduation from an accredited school.
- Experience with MCG or InterQual tooling.
- Ability to obtain additional state licenses if needed.
- 1+ year of utilization review experience in a managed care setting.
- 1+ year of clinical experience, including acute care practice.
Bonus Points
- BSN degree.
- Experience in concurrent or inpatient reviews for a managed care plan.
Benefits & Additional Information
This position offers competitive hourly pay along with employee benefits, including medical, dental, vision, paid holidays, sick time, parental leave, a 401(k) plan, life and disability insurance, wellness time, and reimbursements. Oscar Health is an Equal Opportunity Employer committed to diversity and inclusion.
Key skills/competency
- Utilization Review
- Medical Necessity
- Clinical Guidelines
- RN Licensure
- Nursing
- Managed Care
- Case Review
- Communication
- Compliance
- Acute Care
How to Get Hired at Oscar Health
- Customize your resume: Highlight utilization review and clinical experience.
- Research Oscar Health: Understand their innovative tech approach and member focus.
- Tailor your cover letter: Emphasize experience with clinical guidelines.
- Prepare for behavioral questions: Practice examples from past case reviews.
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