External Appeals Nurse UR Nurse

Oscar Health Insurance Los Angeles , CA 90009

Posted 3 months ago

Hi, we're Oscar. We're hiring an Appeals Utilization Review Nurse to join our Clinical Review Team team in our Los Angeles office.

Oscar is a technology-driven, consumer-focused health insurance startup founded in 2012 and headquartered in New York City. Our goal is to make health insurance simple, transparent, and human. We need your help to do so.

About the role:

Responsible for determining the medical appropriateness of inpatient and outpatient services by reviewing clinical information and applying evidence-based guidelines. Interacting with Oscar providers, members, and internal service teams to obtain necessary information and communicating appeal determinations.

You will report into the Senior Nurse Lead.

Responsibilities:

  • Collect relevant medical information (via telephone, fax, internal database research) and apply the appropriate evidence-based guidelines and medical policy for denied services associated with appeals/grievances

  • Follow documentation guidelines for clear and concise decision-making within our utilization review tracking platform

  • Gather, investigate, and respond re: member and provider clinical appeals/grievances both verbally and in writing

  • Collaborate with regional medical directors and upon direction, communicate appropriately with the regulator/team liaison

  • Meet required decision-making timeframes, including promptly triggering escalation for cases requiring physician review

  • Demonstrate the highest level of professionalism, accountability, and service in your interactions with Oscar teammates, customer service, providers, and members

  • Use Oscar tools and processes to perform and properly track all utilization reviews, as well to refer members for further care engagement when needed

  • Working familiarity with applicable regulatory and accreditation requirements

  • Participate in quality improvement activities as requested

  • Provide feedback into improving Oscar's overall operations and member/provider experience

  • Maintain continued active licensures, professional growth, and education to meet continuing education requirements and demonstrate knowledge & understanding of current nursing care practice

Requirements:

  • 3+ years of internal and external appeals/grievances and utilization review experience at a managed care plan or provider organization, with a thorough and exhaustive understanding of the regulator managed appeals process
  • 5+ years healthcare experience (including at least 2+ years clinical practice in an acute care setting, i.e., ER or hospital)
  • Active, unrestricted RN license

Preferred education and experience

  • BSN

  • Able to multi-task and manage tasks to completion on a timely basis and in an organized fashion

  • Proactive, self-starter, works independently, requires minimal supervision to handle case load once fully trained & operational

  • Familiar with google platforms; willing and able to learn new software tools

Life at Oscar:

Our more than 1,000 employees aim to make health care affordable and accessible for all. We apply this same vision to our perks and benefits, including: medical benefits, generous paid-time off, paid parental leave, retirement plans, company social events, stocked kitchens, wellness programs, and volunteer opportunities.

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 your unique background and perspectives.

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.

Pay Transparency Policy

Oscar ensures that you won't be discharged or discriminated against based on whether you've inquired about, discussed, or disclosed your pay. Read the full policy here.

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External Appeals Nurse UR Nurse

Oscar Health Insurance