Appeals Review Nurse

Hi, we're Oscar. We're hiring an Appeals to join our Clinical Review team.

Oscar is the first health insurance company built around a full stack technology platform and a focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family.

About the role

As an Appeals Nurse you will use evidence-based criteria, plan and regulatory guidelines, and other clinical resources to perform appeal reviews to make recommendations on medical necessity and level of care. 

You will report to the Nurse Supervisor.

Work Location: 

This is a remote role. You must reside in one of the following states: Alabama, Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change.

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Pay Transparency:

The base pay for this role is $35.00 - $45.95 per hour. You are also eligible for employee benefits and monthly vacation accrual at a rate of 10 days per year.

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 SLAs
• Refer members for further care engagement when needed
• Compliance with all applicable laws and regulations
• Other duties as assigned

Qualifications

• Active, unrestricted RN licensure from the United States in [state], 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
• 1+ years of clinical experience (including at least 1+ year clinical practice in an acute care setting, i.e., ER or hospital)
• 1+ years experience with medical decision support tools (i.e. Interqual, MCG, NCCN)

Bonus Points

• Bachelors of Nursing (BSN) degree
• Previous experience conducting concurrent or inpatient reviews for a managed care plan
• 1+ years of appeals experience