Manager, Medical Policy

Oscar Health•Dallas, TX

14d•Remote

About The Position

You will lead the clinical research and development of evidence-based medical necessity criteria within the Office of Clinical Affairs (OCA). You will be responsible for the end-to-end clinical lifecycle of medical policies, ensuring that coverage criteria for medical services, devices and technologies are supported by current clinical literature and nationally recognized standards. You will serve as the lead clinical subject matter expert (SME) for medical evidence appraisal, ensuring our clinical policies are evidence-based, compliant, and supportive of optimal health outcomes for Plan members. You will report into the Associate Director, Clinical Policy - Affordability.

Requirements

Graduate degree in Healthcare Administration, Public Health, Health Policy, Health Services Research, Epidemiology, or a closely related discipline (such as Nursing or another allied health field).
5–8 years in healthcare, with 3–5 years specifically focused on medical policy development, clinical research, or medical writing.
Experience in people leadership, including the ability to manage, mentor, and develop clinical professionals.
Proficiency in leveraging clinical databases (e.g., PubMed) to conduct literature reviews, evaluate evidence, and synthesize findings into defensible medical necessity criteria or recommendations.
Expert ability to interpret complex clinical data and conduct health technology assessments to determine medical coverage standards.

Nice To Haves

Active, unrestricted clinical license (e.g., RN, NP, PA).
Working knowledge of medical coding (e.g. CPT, ICD-10, HCPCS) and claims.
2+ years of experience using Excel/Google Sheets and PowerPoint/Google Slides.
Ability to translate technical clinical evidence for both clinical and non-clinical stakeholders.
Experience with Managed Care regulatory requirements, NCQA standards, and ACA marketplace rules.
Background in managed care, utilization management, or evidence-based clinical guideline development.
Experience in fast-paced, tech-enabled environments with complex cross-functional stakeholder management.

Responsibilities

Lead the review of clinical literature, regulating agency guidance (e.g., FDA, CMS, State/Federal Departments), and specialty society guidelines to develop sound coverage criteria for medical services, devices and technologies.
Conduct and manage health technology assessments for novel medical technologies and complex devices.
Coordinate with internal and external specialty-matching physicians for the clinical review and validation of medical policies.
Translate complex clinical data and evidence-based recommendations into precise, defensible medical necessity criteria and clinical positions or guidance.
Own the end-to-end drafting and maintenance of the medical policy library, ensuring language is clinically accurate, unambiguous, and operationally interpretable.
Responsible for the preparation and presentation of evidence-based medical policies and summaries of changes to the Clinical Advisory Subcommittee (CAS) and internal forums.
Oversee, onboard, develop, and manage a team of clinical FTEs, contractors, and matrixed reports.
Ensure all clinical policy development processes are streamlined and align with the larger departmental and Office of Clinical Affairs (OCA) strategy.
Ensure clinical policy development processes and documentation comply with State, Federal, and NCQA requirements.
Provide support on regulatory audits and quality accreditation surveys as needed.
Compliance with all applicable laws and regulations
Other duties as assigned