Senior Medical Director, Utilization Management

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

Oscar is the first health insurance company built around a full stack technology platform and a 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 take a leadership role in managing the strategy, operations and clinicians of our clinical review (utilization management) function. You will have responsibility for driving process improvement, while interacting with leads from across the organization as a point of accountability and clinical liaison. You will also perform utilization reviews (approximately 10% of the time, and as needed to support the team) as well as lead the clinical policy team.

You will report to the VP & Medical Director, Utilization Management & Case Management

This is a remote / work-from-home role. You must reside in one of the following states: Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Iowa, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change. #LI-Remote

The base pay for this role is: $285,936- $375,291 per year. You are also eligible for employee benefits, company equity grants and annual performance bonuses.

Responsibilities

Strategy, Program Development and Clinical Leadership (90%)

• Develop and implement overall utilization management strategy, including but not limited to:

  • Analyze data to drive operational efficiencies

  • Determine most appropriate services for clinical review

  • Hire, train and audit clinical staff, assuring the proper complement of specialties and competencies for the team

  • Innovate new programs (vendor or otherwise) to improve quality of care and cost of care

  • Ideate, develop and design initiatives that drive affordability within utilization management

• Support and oversee Oscar’s growing team of clinical review clinicians 

• Develop clinical protocols and policies to enhance the quality of medical necessity decision-making, incorporating input from within the clinical review and operations teams, and from other leads (e.g., regional medical directors, quality, care management, data) 

• Monitor and adjust direction based on clinical metrics

• Oversee projects specific to building the team's clinical expertise and efficiency 

• Participate in quality improvement activities (e.g., audits, QA, interrater reliability testing)

• Oversee delegate clinical performance

• Partner with leads across the organization on operational process improvements and member/provider experience involving clinical review tasks

• Serve as point of accountability for escalated clinical issues, including internal and external appeals, member and provider complaints and grievances, and complex case management escalations

• Clinical liaison to P&L leadership related to high cost care and provider contracting, including interfacing with external partners when needed

• Clinical liaison in support of the Payment Integrity function and Claims management

• Provide reporting and regulatory support for the utilization review function as necessary

• Serve as chairperson of the Clinical Advisory Subcommittee and the UM Subcommittee

UM Review (10%)

• Receive and review escalated cases

• Partner with the Market Medical Officers to discuss escalated cases and arrive at appropriate disposition

• Provide clinical determinations based on evidence-based criteria and Oscar internal guidelines and policies, while utilizing clinical acumen, within the appropriate time frames

• Conduct timely peer-to-peer discussions with referring physicians to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence based research

• Clearly document all communication and decision-making in Oscar workflow tools using the correct templates, ensuring a member could easily reference and understand your decision (Flesch-Kincaid grade level)

• 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 professi