Introduction to Oscar Health
Oscar Health is a pioneering healthcare company that is revolutionizing the way healthcare services are delivered and accessed. With a strong commitment to innovation, quality, and patient-centered care, we are dedicated to making healthcare more accessible, affordable, and effective for all. Our team of passionate and dedicated professionals is at the heart of our mission, and we are now seeking an experienced Utilization Reviews Appeals Registered Nurse to join our dynamic Utilization Review team.
About the Role
The Utilization Review Appeals Registered Nurse plays a critical role in our organization, responsible for the investigation and review of clinical appeals and post-claim cases. This involves utilizing clinical knowledge, judgment, and established criteria to determine the medical appropriateness of healthcare services, including inpatient and lower levels of care admissions, as well as a variety of outpatient and specialty services. As an integral part of our team, you will work closely with our medical providers and internal operations teams to ensure that our members receive the highest quality care and support.
Key Responsibilities
- Conduct comprehensive medical necessity reviews and level of care reviews for requested services, utilizing clinical judgment and Oscar Clinical Guidelines, Milliman Care Guidelines
- Obtain necessary information to assess a member's clinical condition, applying evidence-based guidelines to inform decision-making
- Meet required decision-making Service Level Agreements (SLAs) and refer members for further care engagement when needed
- Ensure compliance with all applicable laws and regulations, maintaining the highest standards of integrity and professionalism
- Collaborate with internal stakeholders, including medical providers and operations teams, to achieve shared goals and objectives
- Perform other duties as assigned, demonstrating flexibility and adaptability in a fast-paced and dynamic environment
Qualifications and Requirements
To be successful in this role, you will possess the following essential qualifications and skills:
- Active, unrestricted RN licensure from the United States in one of the following states: Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Iowa, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Virginia, Washington, or Washington, D.C.
- Associate Degree in Nursing or Graduate of Accredited School of Nursing, or successful completion of Diploma Program in Practical Nursing of Accredited School of Nursing
- Ability to obtain additional state licenses to meet business needs, demonstrating flexibility and a commitment to professional development
- Minimum of 1 year of utilization review experience in a managed care setting, with a strong understanding of clinical guidelines and medical necessity criteria
- Minimum of 2 years of clinical experience, including at least 1 year of clinical practice in an acute care setting (e.g., ER or hospital)
Preferred Qualifications
While not required, the following qualifications are highly desirable:
- BSN degree, demonstrating a commitment to advanced education and professional development
- Previous experience conducting concurrent or inpatient reviews for a managed care plan, with a strong understanding of utilization review principles and practices
Skills and Competencies
To excel in this role, you will possess the following skills and competencies:
- Strong clinical knowledge and judgment, with the ability to apply evidence-based guidelines and medical necessity criteria
- Excellent communication and interpersonal skills, with the ability to collaborate effectively with internal stakeholders and external partners
- Strong analytical and problem-solving skills, with the ability to analyze complex data and make informed decisions
- Ability to work independently and as part of a team, with a strong commitment to teamwork and collaboration
- Strong organizational and time management skills, with the ability to prioritize tasks and meet deadlines in a fast-paced environment
Career Growth and Development
- Professional development programs and training initiatives, designed to enhance your clinical knowledge and skills
- Mentorship and coaching, with experienced professionals who can provide guidance and support
- Opportunities for advancement, with a range of career paths and opportunities for professional growth
- A culture of innovation and experimentation, with a strong commitment to trying new things and learning from failure
Work Environment and Company Culture
- Collaboration and teamwork, with a strong emphasis on communication and mutual respect
- Innovation and creativity, with a willingness to try new things and experiment with new approaches
- Professional development and growth, with a commitment to supporting the career aspirations of our employees
- Diversity, equity, and inclusion, with a strong commitment to creating a workplace that is welcoming and inclusive to all
Compensation and Benefits
- A competitive salary, with a range of $35 - $45.94 per hour
- Comprehensive benefits package, including medical, dental, and vision benefits
- 11 paid holidays, paid sick time, and paid parental leave
- 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements
- Opportunities for professional development and growth, with a range of training and education programs
Conclusion
If you are a motivated and experienced Utilization Reviews Appeals Registered Nurse, with a passion for delivering high-quality patient care and a commitment to professional excellence, we encourage you to apply for this exciting opportunity. At Oscar Health, we are dedicated to making healthcare more accessible, affordable, and effective for all, and we believe that you can play a critical role in helping us achieve this mission. Don't hesitate – apply today and join our team of dedicated professionals who are changing the face of healthcare.
How to Apply
To apply for this role, please submit your application through our website. We look forward to hearing from you and exploring how you can contribute to our mission of delivering high-quality, patient-centered care.
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