Associate Medical Director, Utilization Management

About the role

This role determines the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines. This role also influences departmental strategy, leading and overseeing a team of physicians ensuring efficient management and adherence to quality standards.

You will report into the Senior Medical Director.

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.
• 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.
• Manage direct reports and oversee their performance.
• Provide oversight to ensure the team meets turn-around times for clinical reviews.
• Collaborate with other departments on Utilization Management Operations.
• Lead key projects and drive initiatives to successful completion.
• Other duties as assigned
• Compliance with all applicable laws and regulations.

Requirements

• Board certification as an MD or DO with a current unrestricted license to practice medicine is required.
• 3+ years of clinical practice
• 2+ years of utilization review experience in a managed care plan (health care industry)

Bonus points

• 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

Pay Transparency

The base pay for this role is: $240,120 - $315,157 annually. You are also eligible for employee benefits including a performance bonus, 401K with immediate vesting, and unlimited PTO.