Associate Director, Utilization Review

Hi, we're Oscar. We're hiring an Associate Director, Utilization Review to join our Clinical Review 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

Oversees and drives clinical operations and process, supporting managers and supervisors, responsible for the team’s output and strategy (such as budget, staffing, organization direction, etc.), and maintains oversight into the end to end utilization review process (includes appeals) abiding by department compliance at the state level as well as with NCQA and CMS.

You will report into the VP Medical Director, CM and UM. This is a remote / work-from-home role. You must reside in one of the following states: Arizona, California, Connecticut, Florida, Georgia, Illinois, Maryland, Massachusetts, Michigan, New Jersey, New Mexico, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Virginia, or Washington. Note, this list of states is subject to change. #LI-Remote

The potential base pay for this role is: $152,000-$199,500.

Responsibilities

• Manage, and implement clinical strategic initiatives to avoid high cost utilization while ensuring clinical operations meet our needs and align with the company’s mission/values
• Build relationships with the cross-functional company partners by collaborating on process improvement initiatives and overseeing provider facing relationships
• Strategize with and make recommendations to senior leadership on staffing, budget, clinical operational support, optimization, efficiency, & organizational culture, drive process improvement and performance improvement, and ensure feedback is collected from the nursing team and relayed to leadership 
• Collaborate with Clinical & Business Operations to improve efficiency and reduce admin costs
• Manage staffing budget and projections
• Develop the nursing team leaders driving team and individual success
• Understand and support applicable regulatory and accreditation requirements and supporting the team’s quality auditing
• Maintain continued professional growth and education to meet continuing education requirements and demonstrate knowledge & understanding of current nursing care practice

Qualifications

• Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC) 

• Ability to obtain additional state licenses for Oscar's growth (with Oscar's support)

• 5+ years utilization review experience at a managed care plan or provider organization and /or healthcare experience (including at least three years in clinical practice in an acute care setting)
• 5+ years of managerial experience

Bonus Points

• BSN or MS of Nursing
• Commercial and Medicare Advantage expertise  
• Willing and able to learn new software tools

This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here. 

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..

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, paid holidays, paid vacation and sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements.

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.