Utilization Review Nurse

Hi, we're Oscar. We're hiring a Utilization Review Nurse to join our Utilization Review team.

About the 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 the research results for those conditions.

You will report into the Supervisor, Utilization Review.

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.

Pay Transparency: The base pay for this role is: $35.00 - $45.94 per hour. You are also eligible for employee benefits and monthly vacation accrual at a rate of 15 days per year.

Responsibilities:

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

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 Nursing Diploma Program in 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 utilizating 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)

Weekend availability is required; all applicants must be able to work at least one weekend day (Saturday or Sunday) each week.

Bonus points:

BSN

Previous experience conducting concurrent or inpatient reviews for a managed care plan

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Pay Transparency: Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements.

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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.

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