Utilization Review Nurse

ABOUT THE ROLE Oscar is seeking a Utilization Review Nurse to join our Utilization Review team. This role involves performing frequent case reviews, checking medical records, and communicating with care providers as needed. The successful candidate will make recommendations regarding the appropriateness of care for identified diagnoses based on research results for those conditions. WHAT YOU'LL DO As a Utilization Review Nurse, you will be responsible for completing medical necessity reviews and level of care reviews for requested services using clinical judgment and Oscar Clinical Guidelines, Milliman Care Guidelines. You will obtain necessary information to assess a member's clinical condition and apply the appropriate evidence-based guidelines. You will also meet required decision-making SLAs, refer members for further care engagement when needed, and comply with all applicable laws and regulations. WHAT YOU'LL NEED To be successful in this role, you will need to have an active, unrestricted RN licensure from the United States or an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC). You will also need an Associate Degree in Nursing or a Graduate of an Accredited School of Nursing, or successful completion of a Nursing Diploma Program in an Accredited School of Nursing. Additionally, you will need at least one year of utilization review experience in a managed care setting, strong experience utilizing MCG (Milliman Care Guidelines), and at least one year of clinical experience, including at least one year of clinical practice in an acute care setting. WHY REMOTE This is a remote position, open to candidates who reside in Arizona, Florida, Georgia, Illinois, Iowa, Kansas, Michigan, Missouri, Nebraska, New Jersey, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, or Virginia. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. BENEFITS The base pay for this role is $35.00 - $45.94 per hour. You are also eligible for employee benefits, including medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements.