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Utilization Review Nurse

50 minutes ago
United States
Full-time
Junior
Operations Specialist
Operations
Apply Now
Oscar

Oscar

Oscar is a health insurance company that offers plans for individuals, families, and small businesses. With a focus on humanizing health care through technology, design, and data, Oscar provides easy-to-understand bills, 24/7 access to doctors, and a p...

Insurance
1K-5K
Founded 2012
View All Jobs 97

Description

  • Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and clinical guidelines.
  • Obtain and assess member clinical information through telephone and fax communication with care providers and other sources.
  • Review medical records and make recommendations on the appropriateness of care for identified diagnoses.
  • Apply evidence-based guidelines, including Oscar Clinical Guidelines and Milliman Care Guidelines, in review decisions.
  • Meet required decision-making service-level agreements (SLAs).
  • Refer members for further care engagement when needed.
  • Ensure compliance with all applicable laws and regulations.
  • Perform other duties as assigned.

Requirements

  • Active, unrestricted RN licensure in the United States in the relevant state, or an active compact multistate unrestricted RN license under the Nurse Licensure Compact (NLC).
  • Associate degree in nursing, graduation from an accredited school of nursing, or successful completion of a diploma program in practical nursing from an 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.
  • Strong experience using MCG (Milliman Care Guidelines).
  • 1+ year of clinical experience, including at least 1+ year of clinical practice in an acute care setting such as an ER or hospital.
  • BSN preferred.
  • Previous experience conducting concurrent or inpatient reviews for a managed care plan preferred.

Benefits

  • Base pay of $35.00 to $45.94 per hour.
  • Monthly vacation accrual at a rate of 15 days per year.
  • Remote work from home, with eligibility limited to specific U.S. states.
  • Occasional travel may be required for team meetings and company events.
  • Medical, dental, and vision benefits.
  • 11 paid holidays and paid sick time.
  • Paid parental leave.
  • 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements.

Interested in this position?

Apply directly on the company website

Apply Now

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