About the role
Oscar Health is hiring a remote Utilization Review Nurse to evaluate medical necessity and level-of-care requests for its health plan members. You'll apply clinical judgment alongside Oscar's internal guidelines and industry-standard criteria (MCG/InterQual) to review inpatient and outpatient requests, working closely with a Utilization Review supervisor and a broader clinical team.
Responsibilities
- Conduct medical necessity and level-of-care reviews using clinical judgment, Oscar's internal Clinical Guidelines, and MCG/InterQual criteria
- Gather clinical documentation from providers by phone and fax to support review decisions
- Apply evidence-based guidelines consistently while meeting decision-turnaround service levels
- Refer members who need additional care coordination or case management support
- Document review outcomes and maintain compliance with applicable state and federal regulations
- Report to the Supervisor, Utilization Review, and collaborate with the broader clinical review team
Requirements
- Active, unrestricted RN license (or a multistate license under the Nurse Licensure Compact)
- Associate Degree in Nursing or equivalent accredited nursing credential; BSN a plus
- At least 1 year of utilization review experience in a managed-care setting
- At least 1 year of clinical experience, including time in an acute-care setting (ER or hospital)
- Working knowledge of MCG or InterQual review criteria
- Willingness to obtain additional state licenses as needed and to work at least one weekend day per week
- Must reside in one of 17 approved states: AZ, FL, GA, IL, IA, KS, MI, MO, NE, NJ, NC, OH, PA, SC, TN, TX, or VA
What we offer
- Full medical, dental, and vision coverage for full-time employees
- 11 paid holidays plus accrued paid sick time and a monthly vacation accrual (15 days/year)
- Paid parental leave
- 401(k) with company participation
- Company-paid life and disability insurance, plus wellness-time and reimbursement programs