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Job Description

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.

Primary Duties and 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 regulation

We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to [email protected] learn more about how we collect, keep, and process your private information, please review Insight Global's Workforce Privacy Policy: https://insightglobal.com/workforce-privacy-policy/.

Skills and Requirements

Required Experience and Education

• 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) referred Experience and Education

• 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