Physician Reviewer – Utilization Management
| Company | Oscar Health |
|---|---|
| Location | New Mexico, USA, Washington, USA, Kansas, USA, Pennsylvania, USA, Oregon, USA, Iowa, USA, California, USA, Washington, DC, USA, Vermont, USA, Texas, USA, Jackson Township, NJ, USA, Florida, USA, Waterbury, CT, USA, Nevada, USA, South Carolina, USA, Georgia, USA, Arizona, USA, Concord, NH, USA, Tennessee, USA, Virginia, USA, Minnesota, USA, Colorado, USA, Rhode Island, USA, Utah, USA, Kentucky, USA, New York, NY, USA, Maryland, USA, Maine, USA, Massachusetts, USA, North Carolina, USA, Missouri, USA, Ohio, USA, Michigan, USA, Illinois, USA |
| Salary | $211200 – $277200 |
| Type | Full-Time |
| Degrees | MD |
| Experience Level | Senior, Expert or higher |
Requirements
- MD or DO with a current unrestricted license to practice medicine
- Board Certified in Cardiology or Neurology
- 6+ years of clinical practice
- 1+ years of utilization review experience in a managed care plan (health care industry)
Responsibilities
- Provide timely medical reviews that meet Oscar’s stringent quality parameters.
- Provide clinical determinations based on evidence-based criteria and Oscar internal guidelines and policies, while utilizing clinical acumen.
- Clearly and accurately document all communication and decision-making in Oscar workflow tools, ensuring a member could easily reference and understand your decision (Flesch-Kincaid grade level).
- Use correct templates for documenting decisions during case review.
- Meet the appropriate turn-around times for clinical reviews.
- Receive and review escalated reviews.
- Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research.
- Compliance with all applicable laws and regulations
- Other duties as assigned
Preferred Qualifications
- Licensure in multiple Oscar states
- Experience with care management within the health insurance industry
- Willing and able to obtain additional state licensure as business needs, with Oscar’s support