Physician Reviewer - Utilization Management

Oscar Health•Remote, AZ

12d•$219,000 - $286,902•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 reports to the Associate Medical Director, Utilization Management. This is a remote role for candidates residing in the United States, with work completed from a home office. Occasional travel may be required for team meetings and company events. The schedule is 8 a.m. to 5 p.m. in the employee’s local time zone, with a call rotation of one weekend every 16 weeks. The base salary is $219,000–$286,902 per year, and the role is eligible for employee benefits, unlimited vacation, and annual performance bonuses.

Requirements

Board certification as an MD or DO.
Licensure 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 acumen.
Clearly and accurately document communications and decisions in Oscar workflow tools so members can understand and reference decisions.
Use the correct templates to document case-review decisions.
Meet required 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 alternative treatment based on medical-necessity criteria and evidence-based research.
Comply with all applicable laws and regulations.
Perform other duties as assigned.