Utilization Review Nurse
About The Position
Oscar is hiring a Utilization Review Nurse to join their Utilization Review team. In this role, you will perform frequent case reviews, check medical records, and speak with care providers regarding treatment as needed. You will make recommendations regarding the appropriateness of care for identified diagnoses based on research results for those conditions. This is a remote position open to candidates residing in Arizona, Florida, Georgia, Illinois, Iowa, Kansas, Michigan, Missouri, Nebraska, New Jersey, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, or Virginia. While daily work is completed from a home office, occasional travel may be required for team meetings and company events.
Requirements
- Active, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
- Associate Degree - 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
- 1+ year of utilization review experience in a managed care setting
- Strong experience utilizing MCG (Milliman Care Gudielines)
- 1+ years of clinical experience (including at least 1+ year clinical practice in an acute care setting, i.e., ER or hospital)
Nice To Haves
- BSN
- Previous experience conducting concurrent or inpatient reviews for a managed care plan
Responsibilities
- Perform frequent case reviews
- Check medical records
- Speak with care providers regarding treatment as needed
- Make recommendations regarding the appropriateness of care for identified diagnoses based on research results for those conditions
- Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and Oscar Clinical Guidelines, Milliman Care Guidelines
- Obtain the information necessary (via telephone and fax) to assess a member's clinical condition, and apply the appropriate evidence-based guidelines
- Meet required decision-making SLAs
- Refer members for further care engagement when needed
- Compliance with all applicable laws and regulations
- Other duties as assigned
Benefits
- medical
- dental
- vision benefits
- 11 paid holidays
- paid sick time
- paid parental leave
- 401(k) plan participation
- life and disability insurance
- paid wellness time and reimbursements
- monthly vacation accrual at a rate of 15 days per year
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
