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Oscar Health // health insurance
Remote (New York)    Posted: Thursday, October 03, 2019
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Hi, were Oscar. Were a fully licensed health insurer. Our goal is to make healthcare simple, transparent, & human.

We are changing how health insurance works by creating a healthcare experience thats intuitive & puts people, not cost or workflows, first. Were using a consumer-focused & tech-driven approach to do so. This positions us uniquely in the space - & creates one of the biggest opportunities in healthcare.

We brought together leaders from top technology, service & healthcare companies to deliver on our promise & seize this opportunity. We all work side by side in a collaborative, energetic, & creative environment. The result: better people, better ideas, & better healthcare.

In this role, you will play an essential role in building our pharmacy utilization management function. The Clinical Review team is one of Oscars most important clinical functions - we encourage evidence-based practice through utilization review to ensure our members get access to the right care - particularly those who need it most. You will be responsible for understanding & helping to grow our pharmacy utilization management program & driving high quality reviews.

Deliverables: What you have to achieve

Our commitment to high quality decision-making isnt just about checking off the boxes; we aim to raise the bar.

As a Clinical Pharmacist dedicated to high quality pharmacy decision-making & improving the member & provider experience, youll be responsible for:

  • Reviewing prior authorization requests, collecting relevant medical information (via telephone, fax, & portal) & applying the appropriate clinical criteria for medications to make high quality authorization decisions
  • Documenting all communication & decision-making within our utilization review tracking platform, ensuring a peer could easily reference & understand your decision
  • Creating clinical guidelines for individual drugs or therapeutic classes
  • Conducting quality improvement & quality assurance processes to ensure clinical decision-making is accurate, consistent, & compliant to regulatory guidelines
  • Providing clinical support for drug information requests needed by various departments
  • Supporting the development & implementation of medication therapy management programs
  • Learning & using Oscar tools & processes to perform & properly track all pharmacy reviews, as well to refer members for further care engagement when needed
  • Demonstrating the highest level of professionalism, accountability, & service in your interactions with Oscar teammates, customer service, providers, & members
  • Developing a working familiarity with applicable regulatory & accreditation requirements
  • Providing support on regulatory audits & quality accreditation surveys, as needed
  • Supporting the team prepare for expansion into new markets, as needed

Winning factors: What leads to success

Were looking for someone with 3-5 or more years of work experience in managed care. Must-have qualifications & expertise include:

  • Active, unrestricted pharmacy license
  • Degree: Doctor of Pharmacy (PharmD)
  • Willingness to obtain licensure/training with new states, as needed
  • 3+ years of performing pharmacy reviews for a managed care plan
  • Acute attention to detail
  • Excellent written & verbal communication skills
  • A track record for strong, evidence-based clinical decision-making
  • Strong problem-solving skills & comfortable with technology
  • Excited about building tools & thinking outside the box

We think it will make a big (positive) difference if you have:

  • Experience working with the CVS portal & criteria
  • In-depth understanding of how to operationalize step therapy rules & regulations
  • Experience working in a fast-paced, collaborative environment
  • Residency training

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 & find both belonging & support. We're on a mission to change healthcare -- an experience made whole by your unique background & perspectives.

Oscar applicants are considered solely based on their qualifications, without regard to applicants disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team ( 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.

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