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Senior Medical Director, Utilization Management Operations - Remote

Hi, we're Oscar. We're hiring a Senior Medical Director to join our Utilization Management Operations 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

You will oversee the operations of Utilization Management. You will lead a team of clinical leaders who provide oversight of clinicians, provide leadership to managers and are accountable for overall team performance metrics. In collaboration with partners, you will play a key role in strengthening function and driving clinical improvement within the organization.

You will report to the VP, Clinical Operations.

Work Location: 

Oscar is a blended work culture where everyone, regardless of work type or location, feels connected to their teammates, our culture and our mission. 

If you live within commutable distance to our New York City office ( in Hudson Square), our Tempe office (off the 101 at University Ave), or our Los Angeles office (in Marina Del Rey), you will be expected to come into the office at least two days each week. Otherwise, this is a remote / work-from-home role. 

You must reside in one of the following states: Alabama, Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Vermont, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change. #LI-Remote

Pay Transparency:

The base pay for this role is: $280,800 - $368,550 per year. You are also eligible for employee benefits, participation in Oscar’s unlimited vacation program, company equity grants and annual performance bonuses.

Responsibilities

  • Oversee team of clinicians, including nurses and physicians
  • Ensure team is meeting quality and productivity metrics
  • Partner with internal teams to drive continuous improvement
  • Develop a working mastery with applicable regulatory and accreditation requirements and ensure the department / team is meeting those requirements
  • Participate in quality improvement activities (e.g., subcommittees, audits, QA, interrater reliability testing)
  • Partner with leads across the organization as necessary in order to communicate , understand and identify upstream and downstream impacts to the business
  • Support departmental budgeting process including support business case justification for major investments
  • Serve as point of accountability for escalated clinical issues, including internal and external appeals, member and provider complaints and grievances, and complex case management escalations
  • Conduct timely peer-to-peer discussions with referring physicians to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence based research
  • Compliance with all applicable laws and regulations
  • Other duties as assigned

Qualifications

Licensure:

  • MD or DO with a current unrestricted license to practice medicine is required
  • Reviewers must maintain necessary credentials to retain the position including maintaining active board certification
  • Willing and able to obtain additional state licensure (with Oscar’s support)

Experience:

  • 12+ years of experience in the healthcare industry, including:
    • 5+ years of clinical practice and board certification in one of the following specialties: internal medicine, family medicine, general surgery, emergency medicine (other specialties will be considered)
    • 5+ years of utilization management experience in managed care
    • 7+ years experience leading people and teams
    • Experience with Affordable Care Act insurance products

Bonus Points

Licensure:

  • Licensure in multiple Oscar states
  • Masters degree or advanced certificate

Experience:

  • Experience with conducting quality-of-care investigations and peer reviews and developing performance improvement plans

This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here

At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives..

Pay Transparency: 

Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience.

Full-time employees are eligible for 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.

Reasonable Accommodation:

Oscar applicants are considered solely based on their qualifications, without regard to applicant’s disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known.

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Job Profile

Benefits/Perks

11 paid holidays 401(k) plan participation Annual performance bonuses Company equity grants Employee benefits Equity grants Life and Disability insurance Medical, dental, and vision benefits Paid holidays Paid parental leave Paid sick time Paid wellness time and reimbursements Performance bonuses Unlimited Vacation Unlimited vacation program

Skills

Budgeting Clinical Leadership Collaboration Compliance Continuous Improvement Healthcare Leadership Operations Quality improvement Regulatory Compliance Team Management Technology Utilization management

Tasks
  • Compliance
  • Conduct peer-to-peer discussions with referring physicians
  • Continuous Improvement
  • Develop mastery in regulatory requirements
  • Drive continuous improvement
  • Ensure compliance with laws and regulations
  • Ensure quality and productivity metrics are met
  • Handle escalated clinical issues
  • Other duties as assigned
  • Oversee team of clinicians
  • Participate in quality improvement activities
  • Support budgeting process
  • Testing
Experience

12+ years

Education

Business DO M.D.

Certifications

Board Certification

Restrictions

Expected to come into the office at least two days each week if living near specified offices Must reside in specified states