Utilization Review Registered Nurse at Oscar Full Time

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
• 2+ 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)