Physician Reviewer - Utilization Management

About the role:

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

Hours: 8am - 5pm in your local time zone

Call rotation - 1 weekend every 16 weeks

You will report into the Associate Medical Director, Utilization Management.

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

Requirements:

• Board certification as an MD or DO
• 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