Utilization Reviews Appeals Registered Nurse - Remote
Hi, we're Oscar. We're hiring a Utilization Review Appeals RN to join our Utilization Review team.
About the role
The appeals & claims UR nurse is responsible for the investigation and review of clinical appeals and post-claim cases. This involves using clinical knowledge, judgment, and established criteria to determine the medical appropriateness of healthcare services, including inpatient and lower level of care admissions, as well as a variety of outpatient and specialty services. Appeals nurses work as individual contributors completing reviews, and interact regularly with Oscar medical providers and other internal operations teams to successfully fulfill their role.
You will report into the Clinical Appeals Manager.
This is a work-from-home/remote role. You must reside in one of the following states: Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Iowa, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change.
The base pay for this role is: $35 - $45.94 per hour. You are also eligible for employee benefits, monthly vacation accrual up to 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 SLAsRefer 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 …
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Countries Benefits/Perks11 paid holidays 401(k) plan participation Employee benefits Life and Disability insurance Medical, dental, and vision benefits Monthly vacation accrual Monthly vacation accrual up to 10 days per year Paid holidays Paid parental leave Paid sick time Paid wellness time and reimbursements
SkillsClinical Judgment Compliance Healthcare Milliman Care Guidelines Operations Utilization Review
Tasks- Compliance
- Compliance with laws and regulations
- Other duties as assigned
1+ years
EducationAssociate degree Business Diploma
RestrictionsMust reside in specified states