Utilization Review Nurse

🔥 20 hours ago

🌵 Arizona, Florida, +14 more states – Remote

🌵 Arizona – Remote 🐊 Florida – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🌾 Nebraska – Remote 🏖️ New Jersey – Remote 🌲 North Carolina – Remote 🏈 Ohio – Remote 🚗 Michigan – Remote 🏰 Missouri – Remote 🔔 Pennsylvania – Remote 🌴 South Carolina – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⚔️ Virginia – Remote

💵 $35 - $45 / hour

⏰ Full Time

🟢 Junior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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Oscar Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2012

⚕️ Healthcare Insurance

🏥 Healthcare

💰 $355M Post-IPO Debt - Oscar Health on 2025-09

Healthcare Insurance • Healthcare

Oscar Health is a technology-driven health insurance company that provides individual, family, and small-group health plans in multiple U. S. states. Oscar combines traditional insurance underwriting with digital-first services — a consumer-facing app, 24/7 virtual urgent care, prescription delivery (including $3 meds in many plans), and dedicated Care Teams — and also operates Oscar Primary Care in some markets. The company emphasizes accessible, affordable, high-quality care and uses AI to improve member experience and care delivery. Insurance policies are underwritten by Oscar's state insurance subsidiaries and the company offers both HMO and other plan types across its markets.

📋 Description

• Perform frequent case reviews • Check medical records and speak with care providers regarding treatment as needed • Make recommendations regarding appropriateness of care for identified diagnoses based on research results • Report to the Supervisor, Utilization Review • Complete medical necessity reviews and level of care reviews using clinical judgment and Oscar Clinical Guidelines and Milliman Care Guidelines • Obtain information by telephone and fax to assess members’ clinical conditions and apply evidence-based guidelines • Meet required decision-making SLAs • Refer members for further care engagement when needed • Comply with applicable laws and regulations • Perform other duties as assigned

🎯 Requirements

• 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 Nursing Diploma Program in 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 • Strong experience utilizing MCG (Milliman Care Guidelines) or InterQual • 1+ years of clinical experience, including at least 1+ year clinical practice in an acute care setting such as ER or hospital • Weekend availability required; ability to work at least one weekend day each week • BSN is a bonus point • Previous experience conducting concurrent or inpatient reviews for a managed care plan is a bonus point

🏖️ Benefits

• Employee benefits • Monthly vacation accrual at a rate of 15 days per year • Medical, dental, and vision benefits • 11 paid holidays • Paid sick time • Paid parental leave • 401(k) plan participation • Life and disability insurance • Paid wellness time and reimbursements • Occasional travel for team meetings and company events