Physician Reviewer - Utilization Management

Oscar Health•New York, NY

2d•Remote

About The Position

Oscar is hiring a Physician Reviewer to join its Utilization Management team. The role determines the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines. The position is remote for candidates residing in the United States, with work performed from a home office and occasional travel potentially required for team meetings and company events. Hours are 8 a.m. to 5 p.m. in the employee’s local time zone, with one weekend in the call rotation every 16 weeks. The Physician Reviewer reports to the Associate Medical Director, Utilization Management. The base pay is $275,000 per year. The role is also eligible for employee benefits, Oscar’s unlimited vacation, and annual performance bonuses. Final offer amounts within the stated base pay depend on relevant skills, education, and experience.

Requirements

Board certification as an MD or DO.
A license in Florida, North Carolina, or Arizona, or an active Interstate Medical Licensure Compact (IMLC) license.
At least 6 years of clinical practice.

Nice To Haves

Licensure in multiple Oscar states.
At least 1 year of utilization review experience in a managed care plan or the health care industry.
Board certification in Cardiology, Radiation Oncology, or Neurology.
Experience with care management within the health insurance industry.
Willingness and ability to obtain additional state licensure as needed, with Oscar’s support.

Responsibilities

Provide medical reviews that meet Oscar’s quality parameters.
Make clinical determinations using evidence-based criteria, Oscar internal guidelines and policies, and clinical judgment.
Document communications and decisions clearly and accurately in Oscar workflow tools, in language members can understand.
Use the correct templates to document decisions during case review.
Meet appropriate turnaround times for clinical reviews.
Receive and review escalated cases.
Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and explain review decisions, including feedback on alternate treatments based on medical necessity criteria and evidence-based research.
Comply with applicable laws and regulations.
Perform other duties as assigned.