Appeals Review Nurse
Oscar
π΅ $72k-$95k
πRemote - Worldwide
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Job highlights
Summary
Join Oscar's Clinical Review team as an Appeals Nurse to perform appeal reviews and make recommendations on medical necessity and level of care.
Requirements
- 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
- 1+ years of clinical experience (including at least 1+ year clinical practice in an acute care setting, i.e., ER or hospital)
- 1+ years experience with medical decision support tools (i.e. Interqual, MCG, NCCN)
Responsibilities
- Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and Oscar Clinical Guidelines, Milliman Care Guidelines
- Obtain the information necessary (via telephone and fax) to assess a member's clinical condition, and apply the appropriate evidence-based guidelines
- Meet required decision-making SLAs
- Refer members for further care engagement when needed
- Compliance with all applicable laws and regulations
- Other duties as assigned
Preferred Qualifications
- Bachelors of Nursing (BSN) degree
- Previous experience conducting concurrent or inpatient reviews for a managed care plan
- 1+ years of appeals experience
Benefits
- Medical, dental, and vision benefits
- 11 paid holidays
- Paid sick time
- Paid parental leave
- 401(k) plan participation
- Life and disability insurance
- Paid wellness time and reimbursements
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