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Utilization Review Appeals RN

2 months ago

Tempe, United States Oscar Health Full time
Job DescriptionJob Description

Hi, we're Oscar. We're hiring a Utilization Review Appeals RN to join our Clinical Review 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

The UR Appeals nurse is responsible for the investigation and review of clinical appeals and post-claim cases requiring clinical review. You will use clinical knowledge, judgment, and established criteria to determine the medical appropriateness of healthcare services, including inpatient and lower level of care admissions, and a variety of outpatient and specialty services. Appeals nurses work as individual contributors completing reviews, and work with Oscar medical providers and other internal operations teams to fulfill their role.

You will report into Clinical Appeals Nurse Supervisor..

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 Dr), or our Los Angeles office (in Marina Del Rey), you will be expected to 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: Alabama, Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change. #LI-Remote

Pay Transparency:

The base pay for this is: $35 - $45.94 per year. You are also eligible for employee benefits and monthly vacation accrual at a rate of 10 days per year.

Responsibilities
  • Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and other criteria including Oscar Clinical Guidelines, and Milliman Care Guidelines
  • Exercise prudent clinical decision-making to assess a member's clinical condition, and apply appropriate evidence-based guidelines
  • Meet required regulatory and internal timeframes
  • Compliance with all applicable laws and regulations
  • Other duties as assigned
Qualifications
  • 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 Diploma Program in Practical Nursing of 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
  • 2+ years of clinical experience (including at least 1+ year clinical practice in an acute care setting, i.e., ER or hospital)
Bonus Points
  • BSN
  • Previous experience conducting concurrent or inpatient reviews for a managed care plan
  • Previous experience conducting clinical appeals for payor organization

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, 11 paid holidays, paid 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.

California Residents: For information about our collection, use, and disclosure of applicants' personal information as well as applicants' rights over their personal information, please see our Notice to Job Applicants.