Utilization Review Nurse
TLDR
Conduct medical necessity and level-of-care reviews using Oscar Clinical Guidelines and Milliman Care Guidelines to determine appropriate care and engage care providers.
Hi, we're Oscar. We're hiring a Utilization Review Nurse to join our Utilization Review team.
About the role:
You will perform frequent case reviews, check medical records and speak with care providers regarding treatment as needed. You will make recommendations regarding the appropriateness of care for identified diagnoses based on the research results for those conditions.
You will report into the Supervisor, Utilization Review.
Work Location: This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; Illinois; Iowa; Kansas; Michigan; Missouri; Nebraska; New Jersey; North Carolina; Ohio; Oklahoma; Pennsylvania; South Carolina; Tennessee; Texas; or Virginia. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events.
Pay Transparency: The base pay for this role is: $35.00 - $45.94 per hour. You are also eligible for employee benefits and monthly vacation accrual at a rate of 15 days per year.
Responsibilities:
- Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and Oscar Clinical Guidelines, Milliman Care Guidelines
- Obtain the information necessary (via telephone and fax) to assess a member's clinical condition, and apply the appropriate evidence-based guidelines
- Meet required decision-making SLAs
- Refer members for further care engagement when needed
- Compliance with all applicable laws and regulations
- Other duties as assigned
Requirements:
- Active, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
- Associate Degree - Nursing or Graduate of Accredited School of Nursing Or Successful completion of Nursing Diploma Program in Accredited School of Nursing
- Ability to obtain additional state licenses to meet business needs
- 1+ year of utilization review experience in a managed care setting
- Strong experience utilizating MCG (Milliman Care Gudielines)
- 1+ years of clinical experience (including at least 1+ year clinical practice in an acute care setting, i.e., ER or hospital)
Bonus points:
- BSN
- Previous experience conducting concurrent or inpatient reviews for a managed care plan
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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 and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives.
Pay Transparency: Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements.
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Reasonable Accommodation: 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 (accommodations@hioscar.com) to make the need for an accommodation known.
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Benefits
Health Insurance
medical, dental, and vision benefits
Life and disability insurance
Paid Parental Leave
Paid Time Off
monthly vacation accrual at a rate of 15 days per year
Wellness Stipend
paid wellness time and reimbursements
Oscar is a health insurance company leveraging a full-stack technology platform to deliver personalized healthcare experiences. It prioritizes member services, aiming to create a seamless, supportive insurance experience akin to having a trusted family doctor. With a focus on ethical practices, Oscar targets individuals who seek a more responsive and customized approach to health insurance.
- Founded
- Founded 2001
- Employees
- 201-500 employees
- Industry
- Professional Services