Utilization Review Nurse, Appeals
Oscar Health
 Tempe, AZ

Hi, we're Oscar. We’re hiring a Utilization Review Nurse to join our Clinical team in our Tempe office.

Oscar is a technology-driven, consumer-focused health insurance startup founded in 2012 and headquartered in New York City. Our goal is to make health insurance simple, transparent, and human. We need your help to do so.

Appeal/Utilization Review Nurse 

At Oscar, we work hard to provide the kind of health insurance we would want for ourselves. This means that we get to be creative and to build an excellent health insurer from the ground up. 

We're looking for experienced clinicians to join the fast-growing Clinical Review team while supporting the Grievances and Appeals team. We're working to bring a new level of service to utilization review and ensure Oscar members receive access to appropriate care in a timely, transparent way as well strengthen our appeals and grievances process. As a Utilization Review Nurse, you will determine the medical appropriateness of inpatient and outpatient services by reviewing clinical information and applying evidence-based guidelines as well as investigating the request at hand. You will also interact with the internal service teams to obtain necessary information and communicate approval determinations and with Oscar providers, members, regulators whenever applicable related to member/provider appeals. 

Your primary responsibility in this role will be to conduct assessments of medical necessity for inpatient and outpatient services and when applicable as well as investigate and gather clinical information regarding appeals/grievances. In order to do so, you will need to:

  • Collect relevant medical information (via telephone and fax) and apply the appropriate evidence-based guidelines and medical policy and when applicable for denied services associated with appeals/grievances
  • Clearly document all communication and decision-making within our utilization review tracking platform, ensuring a peer could easily reference and understand your decision
  • Gather, investigate, and respond re: member and provider appeals/grievances both verbally and in writing
  • Collaborate with state medical directors and 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, and service in your interactions with Oscar teammates, customer service, providers, and members
  • Learn and use Oscar tools and processes to perform and properly track all utilization reviews, as well to refer members for further care engagement when needed
  • Develop a working familiarity with applicable regulatory and accreditation requirements 
  • Participate in quality improvement activities as requested
  • Provide feedback into improving Oscar's overall operations and member/provider experience
  • Maintain continued professional growth and education to meet continuing education requirements and demonstrate knowledge & understanding of current nursing care practice

Required experience and qualifications include:

Licensure:

  • Active, unrestricted RN or LVN (BSN preferred) license 
  • Willingness to obtain additional state licenses as needed for Oscar's growth (with Oscar's support)
  • Experience of at least:
  • Three years of appeals/grievances and utilization review experience at a managed care plan or provider organization and
  • Five years healthcare experience (including at least 2 years clinical practice in an acute care setting, i.e., ER or hospital)
  • Professional skills:
  • Able to multi-task and manage tasks to completion on a timely basis and in an organized fashion
  • Comfortable with technology; willing and able to learn new software tools
  • Clear written and spoken communication, including a poised phone presence
  • Flexible mindset: we are a fast-moving and evolving startup

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 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.

We encourage our members to care for their whole selves, and we encourage our employees to do the same with comprehensive medical benefits, generous paid-time off, paid parental leave, retirement plans, company social events, stocked kitchens, wellness programs, and volunteer opportunities.

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.

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.