Hi, we're Oscar. Were hiring a Medical Director to join our Pharmacy UM team in our NY office.
Oscar is a technology-driven, consumer-focused health insurance startup founded in 2012 & headquartered in New York City. Our goal is to make health insurance simple, transparent, & human. We need your help to do so.
About the role:
As a Pharmacy Medical Director, you will be part of the team that determines the medical appropriateness of pharmacy services by reviewing clinical information & applying evidence-based guidelines. You will play an essential role in providing the pharmacy utilization management function within our clinical review team which includes non-clinician processors, pharmacy technicians, nurses, pharmacists, & physicians. You will report to the Senior Pharmacy Medical Director. In this role, you will interact with Oscar providers & members, in addition to other parts of our medical operations team, including state medical directors, operational leads, & quality subject matter experts. This is a full-time role that can be remote but geographically close to an Oscar market office.
- Provide clinical determinations based on evidence-based criteria while utilizing your clinical acumen.
- Clearly & accurately document all communication & decision-making in pharmacy workflow tools, ensuring a member could easily reference & understand your decision (Flesch-Kincaid grade level).
- Use & help to improve templates for documenting decisions during case review.
- Meet the appropriate turn-around times for clinical reviews.
- Receive & review escalated reviews (either initial denial or internal / first level appeal).
- Conduct timely peer-to-peer discussions with treating providers to clarify clinical information & outcome decisions, including feedback on alternate treatment based on medical necessity criteria & evidence-based research.
- Develop a working familiarity with applicable regulatory & accreditation requirements as well as Oscar tools & workflows in place to ensure we meet them.
- Demonstrate the highest level of professionalism, accountability, & service in your interactions with Oscar teammates, providers, & members.
Clinical Team Functions
- Support the development & implementation of medication therapy management programs
- Support the maintenance of clinical protocols & policies to enhance the quality of medical necessity decision-making, incorporating input from the clinical review team, operations, & other medical operations leads (state medical directors, quality, pharmacy)
- Support reporting & regulatory needs for the utilization review function for quality & regulatory purposes as necessary
- Participate in quality improvement activities as requested, e.g., QA & training in interrater reliability
- Support projects specific to building the team's clinical expertise & efficiency
- Support the Senior Pharmacy Medical Director on operational improvements & member/provider experience involving clinical review tasks
- ((List 4-5 basic qualifications (BQs) for this role.))
- ((BQs can be identified in the application - not assumed.))
- ((BQs can be identified without reviewing other applications))
- ((EX: 5+ years of experience in banking or Experience leading teams))
- ((Avoid soft skills like "excellent written & verbal communication skills"))
- Active, unrestricted licensure & board certification as an MD or DO
- 3+ years of clinical practice in one of the following fields: internal medicine, family medicine
- License or willingness to obtain state licensure/training (AZ, AR,CA, MI, NJ, NC) as needed & with Oscars support
- 3+ years of performing pharmacy utilization reviews in a managed care plan
- Comfortable with technology; willing & able to learn new software tools
- Acute attention to detail
- Clear written & verbal communication skills
- Outstanding interpersonal skills
- Able to multi-task & manage tasks to completion on a timely basis & in an organized fashion
- A track record for strong, evidence-based clinical decision-making
- Strong problem-solving skills & comfortable with technology
- Excited about building & refining tools & thinking outside the box
Life at Oscar:
At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves & find both belonging & support. We're on a mission to change health care -- an experience made whole by our unique backgrounds & perspectives.
We encourage our members to care for their whole selves, & we encourage our employees to do the same with comprehensive medical benefits, generous paid-time off, paid parental leave, retirement plans, company social events, stocked kitchens, wellness programs, & volunteer opportunities.
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 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.