Hi, were Oscar.
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 improving the quality of decision-making for our 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 clinical policy program & driving quality improvement initiatives.
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 UM Quality Nurse (Clinical Policy & Audit) dedicated to improving both UM decision-making & the member & provider experience, youll be responsible for:
- Drafting clinical policies based on current clinical evidence & nationally-recognized standards
- Tracking evidence submissions & feedback on clinical policies
- Managing a comprehensive clinician onboarding program & support ongoing education
- Learning & using Oscar tools & processes to perform & properly track audits
- Developing, administering, scoring, & reporting on UM interrater reliability tests
- Auditing our UM clinical decision-making, criteria application, & documentation
- Auditing our UM delegate decision-making, criteria application, & documentation
- Supporting clinical leaders in disseminating feedback & conducting remediation
- Monitoring quality trends & identifying gaps to drive quality improvement activities
- Developing an in-depth understanding of regulatory & quality requirements applicable to our programs
- Ensuring processes & documentation are in place & in compliance with State, Federal & NCQA 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. Must-have qualifications & expertise include:
- Active, unrestricted RN (BSN preferred) license
- 2-3 years of clinical research, policy development, and/or medical writing
- 2-3 years of UM quality audit experience
- A passion for improving clinical decision-making & providing feedback to help people improve
- Strong Excel skills
- 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:
- Medical coding experience and/or certification
- Experience building or leading a quality audit & inter-rater reliability program
- Experience with MCG criteria
- Regulatory or compliance experience
- Experience working in a fast-paced, collaborative environment
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 (firstname.lastname@example.org) 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.