Remote Utilization Review Nurse

Summary

Join Oscar's Clinical Review team as a Utilization Review Registered Nurse. Perform frequent case reviews, check medical records, and make recommendations regarding care appropriateness. Report to the Utilization Review Supervisor.

Requirements

• Active, unrestricted RN licensure from the United States 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)

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 Service level agreements
• Refer members for further care engagement when needed
• Compliance with all applicable laws and regulations
• Work schedule includes one weekend day per week
• Other duties as assigned

Benefits

• Medical benefits
• Dental benefits
• Vision benefits
• 11 paid holidays
• Paid sick time
• Paid parental leave
• 401(k) plan participation
• Life and disability insurance
• Paid wellness time and reimbursements