Managing Medical Director, Utilization Management

Hi, we're Oscar. We're hiring a Managing 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 and pharmacy services by reviewing clinical information and applying evidence-based guidelines. Part of Oscar’s clinical review team, interacting with Oscar providers and members, supporting projects aimed at strengthening our utilization review function and team. This role manages full time medical directors and part time physician reviewers  on the team. 

You will report to the Senior Medical Director, Utilization 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: $254,232 - $333,680 per year. You are also eligible for employee benefits, company equity grants and annual performance bonuses.

Responsibilities

• Provide timely medical reviews that meet Oscar’s stringent quality parameters, drive clinical improvement, and educate the clinical staff and physician reviewers. 
• Provide clinical determinations based on evidence-based criteria and Oscar internal guidelines and policies, while utilizing clinical acumen.
• Clearly and accurately document all communication and decision-making in Oscar workflow tools, ensuring a member could easily reference and understand your decision (Flesch-Kincaid grade level)
• Use correct 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 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 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. 

Clinician Team Leadership 

• Manage the full time and part-time physician reviewers on the team by fostering and developing physician reviewer efficiency, competency, and expertise with hands-on leadership and tailored training
• Develop clinical protocols and policies to 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) 
• 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 as well as interventions aimed at Affordability and MLR reduction
• Support the Senior Medical Director for Utilization Management on operational improvements and member/provider experience involving clinical review tasks 

Qualifications

Licensure:

• Board certification as an MD or DO with a current unrestricted license to practice medicine is required
• Reviewers must maintain necessary credentials to retain the position
• 3+ years of clinical practice3+ years of utilization review experience in a managed care plan (health care industry)
• 1+ years of leadership experience as a people manager

Bonus Points

Licensure:

• Licensure in multiple Oscar states (CA, AZ, MO and NC licensure is highly desirable); you should be willing to obtain additional state licenses, with Oscar's support.

Experience:

• Experience with care management or network management within the health insurance industry.
• Experience with conducting quality-of-care investigations and peer reviews and developing performance improvement plans.

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