Hi, we're Oscar. Were hiring an Appeals Utilization Review Nurse to join our Clinical Review Team team in our Los Angeles 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:
Responsible for determining the medical appropriateness of inpatient & outpatient services by reviewing clinical information & applying evidence-based guidelines. Interacting with Oscar providers, members, & internal service teams to obtain necessary information & communicating appeal determinations.
You will report into the Senior Nurse Lead.
- Collect relevant medical information (via telephone, fax, internal database research) & apply the appropriate evidence-based guidelines & medical policy for denied services associated with appeals/grievances
- Follow documentation guidelines for clear & concise decision-making within our utilization review tracking platform
- Gather, investigate, & respond re: member & provider clinical appeals/grievances both verbally & in writing
- Collaborate with regional medical directors & upon direction, communicate appropriately with the regulator/team liaison
- Meet required decision-making timeframes, including promptly triggering escalation for cases requiring physician review
- Demonstrate the highest level of professionalism, accountability, & service in your interactions with Oscar teammates, customer service, providers, & members
- Use Oscar tools & processes to perform & properly track all utilization reviews, as well to refer members for further care engagement when needed
- Working familiarity with applicable regulatory & accreditation requirements
- Participate in quality improvement activities as requested
- Provide feedback into improving Oscar's overall operations & member/provider experience
- Maintain continued active licensures, professional growth, & education to meet continuing education requirements & demonstrate knowledge & understanding of current nursing care practice
- 3+ years of internal & external appeals/grievances & utilization review experience at a managed care plan or provider organization, with a thorough & exhaustive understanding of the regulator managed appeals process
- 5+ years healthcare experience (including at least 2+ years clinical practice in an acute care setting, i.e., ER or hospital)
- Active, unrestricted RN license
Preferred education & experience
- Able to multi-task & manage tasks to completion on a timely basis & in an organized fashion
- Proactive, self-starter, works independently, requires minimal supervision to handle case load once fully trained & operational
- Familiar with google platforms; willing & able to learn new software tools
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 applicants 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.