Senior UM Review Nurse
About The Position
You will leverage clinical knowledge, judgment, and established criteria to determine the medical appropriateness of healthcare services. Senior nurses work as individual contributors completing reviews, and act as subject matter experts (SME). You will interact regularly with peers, Oscar medical providers, and other internal teams to successfully fulfill their role. You will report into the UM Nurse Manager. Work Location:This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; Illinois; Iowa; Kansas; Michigan; Missouri; Nebraska; New Jersey; North Carolina; Ohio; Oklahoma; Pennsylvania; South Carolina; Tennessee; Texas; or Virginia. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events.#LI-Remote
Requirements
- Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
- Associate Degree and/or Bachelors of Nursing from an accredited school of nursing
- 2+ years of utilization review experience at a managed care plan or provider organization
- 2+ years healthcare experience
- MCG Experience
- 1+ years of clinical practice in an acute care setting
Nice To Haves
- Bachelors of Nursing (BSN) degree
Responsibilities
- Gather relevant medical information (via internal resources, ticket, and document review) and complete medical necessity and level of care reviews using clinical judgment and the Plan's clinical guidelines
- Meet required decision-making timeframes, including promptly triggering escalations requiring physician review
- Write clear and concise reviews of inpatient & lower level of care admissions, as well as outpatient and specialty service requests
- Comply with department performance and quality metrics, and adhere to training and remediation requirements
- Support nurse supervisor & managers in daily queue oversight including identifying and flagging clinical trends/issues
- Effectively use Oscar tools to investigate and perform utilization reviews, and to support queue oversight and staffing
- Acts as a clinical resource and escalation point for peers, assists in precepting of newly hired nurse reviewers, and serve as continual champions of the Oscar mission
- Contribute to root cause analysis and process improvement initiatives
- Use working knowledge and familiarity with applicable utilization management regulatory and accreditation requirements on a day to day basis to ensure accurate reviews
- Act as subject matter experts and support the supervisory team in that capacity
- Compliance with all applicable laws and regulations
- Other duties as assigned
Benefits
- medical, dental, and vision benefits
- 11 paid holidays
- paid sick time
- paid parental leave
- 401(k) plan participation
- life and disability insurance
- paid wellness time and reimbursements
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Associate degree
