Physician Reviewer - Utilization Management (Part Time)

About the role

You will determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines.

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.
• Maintain compliance with all applicable laws and regulations.
• 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.
• 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.
• 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.
• 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.

Requirements

• Board certification as an MD or DOL.
• Licensed in one of these states: FL, NC, AZ OR possess an active Interstate Medical Licensure Compact (IMLC).
• 6+ years of clinical practice.
• Bonus Points: Licensure in multiple Oscar states, 1+ years of utilization review experience in a managed care plan (health care industry), BC in Cardiology, Radiation/Oncology, or Neurology, Experience with care management within the health insurance industry, Willing and able to obtain additional state licensure as needed, with Oscar's support.

Qualifications

This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here.

Skills

None specified in the job posting.

Benefits

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.