Medical Director - Pharmacy Utilization Management

  • Oscar
  • Remote
  • Oct 31, 2021
Physician Emergency Medicine General Surgery Internal Medicine

Job Description

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

About the role:

At Oscar, we work hard to provide the kind of health insurance we would want for ourselves. This means that we get to be creative and to build an excellent health insurer from the ground up. We are looking for an experienced physician to support Oscar’s fast-growing Pharmacy Utilization Management team. We are working to bring a new level of service to utilization review and ensure Oscar members receive access to appropriate care in a timely, transparent way. As a Pharmacy Medical Director, you will be part of the team that determines the medical appropriateness of pharmacy and physician administered drug services by reviewing clinical information and applying evidence-based guidelines. You will play an essential role in providing the pharmacy utilization management function within our clinical review team which includes non-clinician processors, pharmacy technicians, nurses, pharmacists, and physicians. You will report to the Senior Pharmacy Medical Director. In this role, you will interact with Oscar providers and members, in addition to other parts of our medical operations team, including state medical directors, operational leads, and quality subject matter experts. 

Responsibilities:

  • Provide clinical determinations based on evidence-based criteria and Oscar internal guidelines and policies while utilizing your clinical acumen.

  • Clearly and accurately document all communication and decision-making in pharmacy workflow tools, ensuring a member could easily reference and understand your decision (Flesch-Kincaid grade level).

  • Correctly use and help improve templates for documenting decisions during case review.

  • Meet the appropriate turn-around times for clinical reviews.

  • Receive and review escalated reviews 

  • Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and outcome decisions including feedback on alternate treatment based on medical necessity criteria and evidence-based research.

  • Develop a working familiarity with applicable regulatory and accreditation requirements as well as Oscar tools and workflows in place to ensure we meet them.

  • Demonstrate the highest level of professionalism, accountability, and service in your interactions with Oscar teammates, providers, and members. 

Requirements:

  • Active, unrestricted licensure and board certification as an MD or DO

  • 3+ years of clinical practice in one of the following fields: primary care, emergency medicine, general surgery

  • License or willingness to obtain state licensure/training (AR, AZ,CA, NC, TX) as needed and with Oscar’s support

  • Experience performing utilization management within the health insurance industry

Bonus points:

  • Experience working with the CVS portal and criteria

  • Experience working in a fast-paced, collaborative environment

  • Strong problem-solving skills

  • A track record for strong, evidence-based clinical decision-making

  • Understanding of managed care regulatory structure and processes

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 aim to make health care affordable and accessible for all, and apply this same vision to our perks and benefits, including: 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.

COVID-19 vaccine requirements for in-person work: 

To protect the health and safety of our employees, we require any employee conducting in-person work* to be fully vaccinated against COVID-19 by their start date. If you are unable to be vaccinated due to medical or protected religious reasons, please reach out to our Benefits team at accommodations@hioscar.com to submit an accommodations request.

*Note: In-person work includes: employees required to work from our offices, employees conducting sales work in the field and employees conducting at-home or in-person visits with members.