Physician Reviewer – Utilization Management

This is a fully remote position, open to applicants in Arizona, +2 more states.

📋 Description

• Assess the medical appropriateness of inpatient, outpatient, and pharmacy services by analyzing clinical information and applying evidence-based guidelines.

• Conduct medical reviews that align with Oscar's quality standards.

• Make clinical determinations grounded in evidence-based criteria, internal guidelines, policies, and professional expertise.

• Record communications and decision-making processes in Oscar workflow tools utilizing the appropriate templates.

• Adhere to turnaround times for clinical reviews.

• Handle and evaluate escalated reviews.

• Engage in peer-to-peer discussions with treating providers to clarify clinical information and communicate review outcomes.

• Offer feedback on alternative treatments based on medical necessity criteria and evidence-based research.

• Ensure compliance with relevant laws and regulations.

• Execute other duties as assigned.

• Report directly to the Associate Medical Director of Utilization Management.

• Participate in a call rotation, taking calls one weekend every 16 weeks.

⛳️ Requirements

• Board certification as an MD or DO.

• Licensed in Florida, North Carolina, or Arizona, or hold an active Interstate Medical Licensure Compact (IMLC).

• Minimum of 6 years of clinical practice experience.

• Willingness and ability to acquire additional state licensure as necessary, with support from Oscar.

• Multi-state licensure within Oscar markets is advantageous.

• Over 1 year of experience in utilization review within a managed care plan is a plus.

• Board certification in Cardiology, Radiation/Oncology, or Neurology is a bonus.

• Background in care management within the health insurance sector is beneficial.

🏝️ Benefits

• Comprehensive employee benefits.

• Unlimited vacation policy at Oscar.

• Annual performance bonuses.

• Medical benefits.

• Dental benefits.

• Vision benefits.

• 11 paid holidays.

• Paid sick leave.

• Paid parental leave.

• Participation in a 401(k) plan.

• Life and disability insurance.

• Paid wellness time and reimbursement options.

• Support from Oscar to obtain additional state licensure as needed.