Medical Director, Utilization Management

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 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 medical and pharmacy services by reviewing clinical information and applying evidence-based guidelines. Part of Oscar’s clinical review team, working with Oscar providers and teams supporting projects aimed at strengthening our utilization review team, including oversight and management of Oscar’s clinical policy strategy and function. You will manage the medical policy team, medical directors and physician reviewers. You will have a close business and operational relationship with the pharmacy team.

You will report to the Senior Medical Director, Utilization Management.

Work Location: 

Oscar is a blended work culture where everyone, regardless of work type or location, feels connected to their teammates, our culture and our mission. 

If you live within commutable distance to our New York City office ( in Hudson Square), our Tempe office (off the 101 at University Ave), or our Los Angeles office (in Marina Del Rey), you will come into the office at least two days each week. Otherwise, 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

Pay Transparency:

The base pay for this role is: $255,200 - $334,950 per year. You are also eligible for employee benefits, participation in Oscar’s unlimited vacation program, company equity grants and annual performance bonuses.

 

Responsibilities

80%

• Manage the clinician team by promoting and developing efficiency, competency, and expertise with hands-on leadership and tailored training
• Develop clinical protocols and medical policies to drive authorization strategy and enhance the quality of medical necessity decision-making, incorporating input from the clinical review team, operations, and other medical operations leads (state medical directors, quality, pharmacy) 
• Maintain a data driven approach to drive prioritization in creation of medical policies, clinical coding edits and clinically-focused claims payment strategies. 
• Support reporting and regulatory needs for the utilization review function for quality and regulatory purposes as necessary.
• Participate in quality improvement activities as requested, e.g., QA and training in interrater reliability. 
• Support projects specific to building the team's clinical expertise and efficiency. 
• Support the Senior Medical Director for Utilization Management in operational improvements and member/provider experience.
• Supports the pharmacy team with pharmacy policy development, vendor delegate oversight and regulatory tasks.
• Participates in Oscar Pharmacy external and internal subcommittees.
• The medical POC for the pharmacy team for clinical formulary questions and affordability measures.
• Provide medical reviews that meet Oscar’s stringent quality parameters, improve, and educate the clinical staff.. 
• Provide clinical determinations based on evidence-based criteria and Oscar internal guidelines and policies, while using clinical knowledge.
• 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 and Oscar tools and workflows in place to ensure we meet them. 

20%

• Provide medical reviews that meet Oscar’s stringent quality parameters, improve, and educate the clinical staff.
• Provide clinical determinations based on evidence-based criteria and Oscar internal guidelines and policies, while using clinical knowledge.
• 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 rese