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Salary: USD 219,000 - 286,902 / annual
Oscar Health is seeking a Physician Reviewer to join its Utilization Management team. In this role, you will review clinical information and determine the medical appropriateness of inpatient, outpatient, and pharmacy services using evidence-based guidelines and Oscar's internal policies.
Key responsibilities include:
- Conducting medical reviews that meet Oscar's quality standards
- Making clinical determinations based on evidence-based criteria and clinical judgment
- Documenting all communications and decisions clearly in Oscar's workflow tools, ensuring members can understand decisions
- Using correct templates for case documentation
- Meeting appropriate turnaround times for clinical reviews
- Reviewing escalated cases
- Conducting peer-to-peer discussions with treating providers to clarify clinical information and explain review decisions
- Ensuring compliance with applicable laws and regulations
You will report to the Associate Medical Director of Utilization Management. The role operates 8am–5pm in your local time zone with a call rotation of one weekend every 16 weeks. While work is completed remotely from your home office, occasional travel may be required for team meetings and company events.
Required qualifications:
- MD or DO with board certification
- Active medical license in Florida, North Carolina, Arizona, or possession of an active Interstate Medical Licensure Compact (IMLC) credential
- 6+ years of clinical practice
Bonus qualifications include licensure in multiple Oscar states, 1+ years of utilization review experience in managed care, board certification in Cardiology, Radiation/Oncology, or Neurology, and experience with care management in health insurance.
