Hi, we're Oscar. Were hiring a Clinical Appeals Liaison to join our Clinical Review Team.
Oscar is the first health insurance company built around a full stack technology platform & a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselvesone that behaves like a doctor in the family.
About the role:
This role will be accountable for processing clinical appeals for Oscar individual market lines. The role includes intake, assessment, & coordination of appeals, as well as liaising with various external agencies including state regulators & other third parties responsible for health plan administration & Oscars internal Clinical Review Team.
This role is responsible for assessing the eligibility of the appeals, gathering case documentation & medical records, & ensuring that we meet the requested or established timeframe requirements.
You will report into the Senior Nurse Lead. This is a remote role, you are able to work remotely in one of the following states: Arizona, California, Connecticut, Florida, Georgia, Illinois, Maryland, Massachusetts, Michigan, New Jersey, New Mexico, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Virginia, or Washington. Note, this list of states is subject to change.
- Assess incoming requests & inquiries for appeals, swiftly determining next steps & taking appropriate action
- Timely & comprehensive resolution, abiding by internal SLAs as well as stated mandated turnaround times
- Conduct a comprehensive review of case history & identify key elements, arguments & mitigating factors
- Outreach to providers for medical records & to members as needed to gather details relevant to the appeals
- Build tickets & gather case documents. Provide clear & accurate documentation in the ticketing system as to the progress & status of your work.
- Oversight & ownership of casework & timelines
- Establish a strong rapport with the Clinical & CGA Teams; escalating & coordinating with clinical staff where needed
- Escalation & coordination with the CGA staff when cases must be referred to the complaints, appeals and/or regulator teams
- Work as a team to complete departmental tasks to meet deadlines & accomplish department objectives. This may include evenings, weekends & holidays
- 2+ years healthcare experience (clinical practice in an outpatient or acute care setting) or working with health plans, coordinating care, authorizations and/or appeals
- Knowledge of insurance industry & regulatory compliance to applicable state & federal laws
- Bachelor's Degree
- Strong proficiency navigating & working in multi-system environment (customer service, case management, claims)
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 aim to make health care affordable & accessible for all, & 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.
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.
COVID-19 vaccine requirements for in-person work:
To protect the health & safety of our employees, we require any employee conducting in-person work* to be fully vaccinated against COVID-19 by their start date.
If you are unable to be vaccinated due to medical or protected religious reasons, please reach out to our Benefits team at firstname.lastname@example.org to submit an accommodations request.
*Note: In-person work includes: employees required to work from our offices (either full-time or part-time), employees conducting sales work in the field & employees conducting at-home or in-person visits with members.