What is the position?
Hi, were Oscar. Were a fully licensed health insurer. Our goal is to make healthcare simple, transparent, & human.
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 launching our Medicare Advantage business. When you come in, you will be a leader on our Clinical Review team; one of Oscars most important clinical functions. This team encourages 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 building & overseeing our utilization review Medicare responsibilities which includes aspects of the CMS application, the operationalization of the all relevant requirements, & ensuring operational readiness.
This is an exciting opportunity to be at the forefront of growth at Oscar, helping enable our innovative model to reach new members.
What is the position?
- Be the senior leader responsible for Medicare Advantage Utilization Review Operations
- Drive & successfully complete the annual CMS application process
- Developing & executing a utilization review workplan collaboratively with operational teams
- Creating utilization review application materials
- Own, drive & successfully prepare for operational readiness & CMS audit
- Perform internal gap analysis for operational readiness
- Develop a workplan to close gaps for CMS audit & operational readiness including building people, process & technology infrastructure
- Oversee development of all policies & procedures
- Partner with Product in establishing the operational processes
- Support audit readiness assessment jointly with Compliance
- Lead the Medicare Advantage utilization review team
- Build & implement measurable, repeatable, scalable, & predictable processes.
- Drive continuous improvement to enable this product line to scale efficiently & effectively.
Who are you?
- You have a Nursing Degree, Bachelors Degree or higher
- You have over five years+ managerial experience over a managed care medical management system
- Your have comprehensive knowledge of Medicare insurance regulations & experience with State & external accreditation managed care audits & reviews required
- You have experience in case management, disease management, utilization management & program development using evidence based medicine required
- You have experience in Medicare bid process & benefit design is preferred
- You have prior success in healthcare integration, process development & program implementation is desirable.
- You have experience in & enjoy managing large projects that require strong organizational skills & collaborating with a broad array of different teams within an organization
- You are a critical thinker who can distill complex concepts & regulatory requirements into easy to understand action items
- You have acute attention to detail & always strive for perfection when writing formal documents.
- You get things done, even if its crunch time
- You have passion for healthcare & a knack for making processes more systematic