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Medicare Advantage Clinical Review Senior Manager

| Greater NYC Area

What is the position?

Hi, we’re Oscar. We’re a fully licensed health insurer. Our goal is to make healthcare simple, transparent, and human.

We are changing how health insurance works by creating a healthcare experience that’s intuitive and puts people, not cost or workflows, first. We’re using a consumer-focused and tech-driven approach to do so. This positions us uniquely in the space - and creates one of the biggest opportunities in healthcare.

We brought together leaders from top technology, service and healthcare companies to deliver on our promise and seize this opportunity. We all work side by side in a collaborative, energetic, and creative environment. The result: better people, better ideas, and better healthcare.

In this role, you will play an essential role in launching our Medicare Advantage business. When you come in, you will be a leader on our Clinical Review team; one of Oscar’s most important clinical functions. This team encourages evidence-based practice through utilization review to ensure our members get access to the right care - particularly those who need it most. You will be responsible for building and overseeing our utilization review Medicare responsibilities which includes aspects of the CMS application, the operationalization of the all relevant requirements, and ensuring operational readiness.

This is an exciting opportunity to be at the forefront of growth at Oscar, helping enable our innovative model to reach new members.

What is the position?

  • Be the senior leader responsible for Medicare Advantage Utilization Review Operations
    • Drive and successfully complete the annual CMS application process
    • Developing and executing a utilization review workplan collaboratively with operational teams
    • Creating utilization review application materials
  • Own, drive & successfully prepare for operational readiness and CMS audit
    • Perform internal gap analysis for operational readiness
    • Develop a workplan to close gaps for CMS audit & operational readiness including building people, process and technology infrastructure
    • Oversee development of all policies & procedures
    • Partner with Product in establishing the operational processes
    • Support audit readiness assessment jointly with Compliance
  • Lead the Medicare Advantage utilization review team
    • Build and implement measurable, repeatable, scalable, and predictable processes.
    • Drive continuous improvement to enable this product line to scale efficiently and effectively.

Who are you?

  • You have a Nursing Degree, Bachelor’s Degree or higher
  • You have over five years+ managerial experience over a managed care medical management system
  • Your have comprehensive knowledge of Medicare insurance regulations and experience with State and external accreditation managed care audits and reviews required
  • You have experience in case management, disease management, utilization management and program development using evidence based medicine required
  • You have experience in Medicare bid process and benefit design is preferred
  • You have prior success in healthcare integration, process development and program implementation is desirable.
  • You have experience in and enjoy managing large projects that require strong organizational skills and collaborating with a broad array of different teams within an organization
  • You are a critical thinker who can distill complex concepts and regulatory requirements into easy to understand action items
  • You have acute attention to detail and always strive for perfection when writing formal documents.
  • You get things done, even if it’s crunch time
  • You have passion for healthcare and a knack for making processes more systematic
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