Experienced Utilization Reviews Appeals Registered Nurse – Remote Opportunity for Clinical Excellence and Professional Growth

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