Senior Medical Director - Utilization Management
At Oscar, we work hard to provide the kind of health insurance we would want for ourselves. This means that we get to be creative and to build an excellent health insurer from the ground up.
We're looking for an experienced physician to support Oscar's fast-growing Utilization Management team. We're working to bring a new level of service to utilization review and ensure Oscar members receive access to appropriate care in a timely, transparent way. As Oscar’s Senior Medical Director for utilization review, you will take a leadership role in managing the clinicians on our clinical review You will have responsibility for scheduling the Medical Director reviewers, leading process improvement and participating in reviews (determining the medical appropriateness of inpatient and outpatient services by reviewing clinical information and applying evidence-based guidelines).
In this role, you will interact with Oscar providers, members, other parts of our medical operations team, including state Medical Directors, operational leads, quality and pharmacy. You will support projects aimed at strengthening our utilization review function and team. This is a full-time role. Although the role can be remote, a significant presence is needed in our Tempe clinical operations center and in our New York corporate office (to a lesser degree). The role reports to Oscar's National Medical Director for clinical review and will be partnered with our operational lead for Utilization Management.
Your primary responsibility in this role will be to oversee the clinicians on the review team, drive clinical improvement within the process and provide timely medical review for utilization review requests (approximately 25% of the time). More specifically, you will need to:
Clinician Team Leadership
- Support and oversee Oscar’s growing clinician review team (physician reviewers, nurse leads, and nurse reviewers).
- Develop clinical protocols and policies to enhance the quality of medical necessity decision-making, incorporating input from the clinical review team, operations, and other medical operations leads (state medical directors, quality, pharmacy)
- Support reporting and regulatory needs for the utilization review function for quality and regulatory purposes
- Participate in quality improvement activities as requested, e.g., QA and training in interrater reliability
- Oversee projects specific to building the team's clinical expertise and efficiency
- Partner with operational lead on operational improvements and member/provider experience involving clinical review tasks
UM Review (25%)
- Receive escalated reviews (either initial denial or internal / first level appeal) from core UR team
- Provide determinations based on your relevant expertise, evidence-based criteria, and Oscar internal guidelines and policies within the appropriate time frames
- Conduct timely peer-to-peer discussions with referring physicians to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence based research
- Clearly and accurately document all communication and decision-making in Oscar workflow tools, ensuring a peer could easily reference and understand your decision
- Develop a working familiarity with applicable regulatory and accreditation requirements as well as Oscar tools and workflows in place to ensure we meet them
- Demonstrate the highest level of professionalism, accountability, and service in your interactions with Oscar teammates, providers, and members
Required experience and qualifications include:
- MD or DO with a current unrestricted license to practice medicine in the US. Licensure in multiple Oscar states (CA, NJ, NY, TX, OH, NJ, FL, MI, AZ) preferred but not required; you should be willing to obtain additional state licenses, with Oscar's support.
- Reviewers must maintain necessary credentials to retain the position.
- Board certified or eligible
- 3+ years years clinical practice in one of the following fields: internal medicine, family medicine, general surgery, emergency medicine (other areas such as Pediatrics will be considered)
- 2-3+ years utilization review experience in a managed care setting
- Professional skills:
- Able to multi-task and manage tasks to completion on a timely basis and in an organized fashion
- Comfortable with technology; willing and able to learn new software tools
- Clear written and spoken communication
- Flexible mindset: we are a fast-moving and evolving startup
- Ability to travel up to 25%