Medical Director, Utilization Management

  • Oscar
  • Remote
  • Oct 04, 2021
Physician Emergency Medicine Family Medicine General Surgery Internal Medicine Pediatrics

Job Description

Hi, we're Oscar. We're hiring a Medical Director to join our Utilization Management team.

Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family.

About the role:

You will determine the medical appropriateness of inpatient, outpatient and pharmacy services by reviewing clinical information and applying evidence-based guidelines. As a Part of Oscar's clinical review team, including non-clinician processors, nurses and part-time physicians interacting with Oscar providers and members, in addition to other parts of our medical operations team, including regional medical directors, operational leads, and quality and pharmacy subject matter experts. You will support projects aimed at strengthening our utilization review function and team.

You will report into the Senior Medical Director. This is a remote role, you will work remotely in one of the following states: Arizona, California, Connecticut, Florida, Georgia, Illinois, Maryland, Massachusetts, Michigan, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Tennessee, Texas, Utah, Virginia, or Washington. Note, this list of states is subject to change.

Responsibilities:

  • Provide medical reviews that meet Oscar's stringent quality parameters, drive clinical improvement, and educate the clinical staff and part-time physician reviewers.
  • Provide clinical determinations based on evidence-based criteria and Oscar internal guidelines and policies, while utilizing clinical acumen.
  • Clearly and accurately document all communication in Oscar workflow tools, ensuring a member could easily reference and understand your decision (Flesch - Kincaid grade level)
  • Use correct templates for documenting decisions during case review.
  • Meet the appropriate turn-around times for clinical reviews.
  • Receive and review escalated reviews.
  • Conduct peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research.
  • Working familiarity with applicable regulatory and accreditation requirements as well as Oscar tools and workflows in place to ensure we meet them.

Requirements:

  • Board certification as an MD or DO with a current unrestricted license to practice medicine is required.
  • Reviewers must maintain necessary credentials to retain the position.
  • 3+ years of clinical practice in one of the following fields: internal medicine, family medicine, general surgery, emergency medicine, pediatrics
  • 3+ years of utilization review experience in a managed care plan (health care industry
  • Licensure in multiple Oscar states (CA, AZ, MO and NC licensure is highly desirable); you should be willing to obtain additional state licenses, with Oscar's support.
  • Experience with care management within the health insurance industry.
  • Experience with conducting quality-of-care investigations and peer reviews and developing performance improvement plans.

Life at Oscar:

At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives.

We encourage our members to care for their whole selves, and we encourage our employees to do the same with comprehensive medical benefits, generous paid-time off, paid parental leave, retirement plans, company social events, stocked kitchens, wellness programs, and volunteer opportunities.

Reasonable Accommodation:

Oscar applicants are considered solely based on their qualifications, without regard to applicant's disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known.

Pay Transparency Policy:

Oscar ensures that you won't be discharged or discriminated against based on whether you've inquired about, discussed, or disclosed your pay. Read the full policy here.