Hi, we're Oscar. We're hiring a Utilization Review & Nurse Care Coordinator to join our Clinical Review Team team in Miami, Florida.
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:
RN Care Coordinator & Utilization Review Nurse work onsite at Oscar contracted hospitals to determine the medical appropriateness of inpatient & outpatient services by reviewing clinical information & applying evidence-based guidelines & assisting with discharge planning & coordination of post-acute care for Oscar members. Also working with Oscar providers, members, & internal service team to obtain necessary information & communicate approval determinations, & coordinate care.
You will report into the Utilization Review Nurse Manager.
- Collect relevant medical information (onsite via EMR) & apply the appropriate evidence-based guidelines & medical policies to determine medical necessity which could include Oscar Clinical Guidelines, Milliman Care Guidelines, Hayes, UpToDate, etc.
- Initiate onsite hospital to assess patient progress & meet with appropriate members of the patient care team/family members
- Conduct initial facility visit to engage & educate the member (and their family/caregivers)
- Routinely conduct in-facility visits to monitor the member's adherence to their established care plans
- Coordinate with office management team in developing & managing an outcome-based plan of care, based on the member's input & assesses member clinical & social needs with anticipated targeted dates for accomplishment
- Evaluate expected outcomes & associated costs of the plan of care as well as any proposed alternative plan of care & make the necessary revisions
- Coordinate, monitor, track & evaluate all care & services given to ensure that quality care is being delivered in the most appropriate setting
- Discuss unresolved members' care concerns with the care team to make adjustments
- Manage transition of care ensuring that the Plan of Care moves with the member & updates/modifies the care plan as the member's health care status changes
- Identify & address psychosocial needs of the members & family & organize consultations with Oscar's Care Management/Concierge teams
- Coordinate with office management team to identify & address pharmacological needs of the members & promote consultations with the pharmacy department
- Coordinate with office management team to ensure the post-discharge clinic appointments, medication reconciliation, PCP & specialist visits have been made before discharge
- 3+ years utilization review experience at a managed care plan or provider organization and
- 5+ years clinical experience (including at least 2 years clinical practice in an acute care setting, i.e., ER or hospital; case management or discharge planning experience in an acute care setting, home health, or home hospice)
- Active, unrestricted RN - Willingness to obtain additional state licenses as needed for Oscar's growth
- BSN license
- Bilingual in Spanish
Life at Oscar:
Our more than 1,000 employees aim to make health care affordable & accessible for all. We apply this same vision to our perks & benefits, including: medical benefits, generous paid-time off, paid parental leave, retirement plans, company social events, stocked kitchens, wellness programs, & volunteer opportunities.
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 your unique background & 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@example.com) 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.