Medicare Advantage Clinical Review Senior Manager

| Greater NYC Area

What is the position?

Hi, we’re Oscar. We’re a fully licensed health insurer. Our goal is to make healthcare simple, transparent, and human.

We are changing how health insurance works by creating a healthcare experience that’s intuitive and puts people, not cost or workflows, first. We’re using a consumer-focused and tech-driven approach to do so. This positions us uniquely in the space - and creates one of the biggest opportunities in healthcare.

We brought together leaders from top technology, service and healthcare companies to deliver on our promise and seize this opportunity. We all work side by side in a collaborative, energetic, and creative environment. The result: better people, better ideas, and better healthcare.

In this role, you will play an essential role in launching our Medicare Advantage business. When you come in, you will be a leader on our Clinical Review team; one of Oscar’s most important clinical functions. This team encourages evidence-based practice through utilization review to ensure our members get access to the right care - particularly those who need it most. You will be responsible for building and overseeing our utilization review Medicare responsibilities which includes aspects of the CMS application, the operationalization of the all relevant requirements, and ensuring operational readiness.

This is an exciting opportunity to be at the forefront of growth at Oscar, helping enable our innovative model to reach new members.

What is the position?

  • Be the senior leader responsible for Medicare Advantage Utilization Review Operations
    • Drive and successfully complete the annual CMS application process
    • Developing and executing a utilization review workplan collaboratively with operational teams
    • Creating utilization review application materials
  • Own, drive & successfully prepare for operational readiness and CMS audit
    • Perform internal gap analysis for operational readiness
    • Develop a workplan to close gaps for CMS audit & operational readiness including building people, process and technology infrastructure
    • Oversee development of all policies & procedures
    • Partner with Product in establishing the operational processes
    • Support audit readiness assessment jointly with Compliance
  • Lead the Medicare Advantage utilization review team
    • Build and implement measurable, repeatable, scalable, and predictable processes.
    • Drive continuous improvement to enable this product line to scale efficiently and effectively.

Who are you?

  • You have a Nursing Degree, Bachelor’s Degree or higher
  • You have over five years+ managerial experience over a managed care medical management system
  • Your have comprehensive knowledge of Medicare insurance regulations and experience with State and external accreditation managed care audits and reviews required
  • You have experience in case management, disease management, utilization management and program development using evidence based medicine required
  • You have experience in Medicare bid process and benefit design is preferred
  • You have prior success in healthcare integration, process development and program implementation is desirable.
  • You have experience in and enjoy managing large projects that require strong organizational skills and collaborating with a broad array of different teams within an organization
  • You are a critical thinker who can distill complex concepts and regulatory requirements into easy to understand action items
  • You have acute attention to detail and always strive for perfection when writing formal documents.
  • You get things done, even if it’s crunch time
  • You have passion for healthcare and a knack for making processes more systematic
Read Full Job Description

Technology we use

  • Engineering
  • Product
    • C#Languages
    • C++Languages
    • JavaLanguages
    • JavascriptLanguages
    • PythonLanguages
    • RLanguages
    • SqlLanguages
    • Google AnalyticsAnalytics

Location

295 Lafayette St, New York, NY 10012

An Insider's view of Oscar

What’s the vibe like in the office?

The vibe in the office super collaborative. I’ve never been at any company before where so many different departments work so closely together to accomplish the same vision and goals. It doesn’t matter if your team is member facing or not, the vision is the same - making health care simpler and easier to understand for our members.

Gabriela

Senior IT Technician

What's the biggest problem your team is solving?

We are striving to make a healthier life accessible and affordable for all. Everything we do is aligned towards solving that high-level problem and given the state of healthcare in the United States it is no easy task.

Isaac

VP, Engineering

What does career growth look like on your team?

As the product design director, it’s my responsibility to set the design team up for success. That means designers understand how they're performing now, how they're expected to grow and how they fit into the company’s future. At Oscar, one of our core values is 'powered by people' -- developing and growing our employees is what raises the bar.

Erin

Director, Product Design

How do you make yourself accessible to the rest of the team?

I believe accessibility is critical to effective leadership. Being accessible is not only about making time for your team, but also about fostering emotional and human connections with those around you. We have various forums in which I make myself accessible to the team, including an open door policy if anyone needs me for anything at anytime.

Sara

SVP, Product

What are some social events your company does?

Oscar does a great job of 'reading the room'. We have birthday celebrations and celebrate work anniversaries often. In addition, the "surprise & delight" events are always thoughtful, focusing on happiness, mental health, and just providing a plain old reason to take a breather. Nothing beats the company-wide camping trip over the summer though!

Blake

Recruiter II

What are Oscar Perks + Benefits

Oscar Benefits Overview

Great perks for every employee.

Health Insurance & Wellness Benefits
Flexible Spending Account (FSA)
Disability Insurance
Dental Benefits
Vision Benefits
Health Insurance Benefits
Life Insurance
Wellness Programs
Retirement & Stock Options Benefits
401(K)
401(K) Matching
Company Equity
Performance Bonus
Child Care & Parental Leave Benefits
Generous Parental Leave
Flexible Work Schedule
Family Medical Leave
Vacation & Time Off Benefits
Unlimited Vacation Policy
Generous PTO
Sabbatical
Paid Holidays
Paid Sick Days
Perks & Discounts
Beer on Tap
In our NYC and LA offices.
Casual Dress
Commuter Benefits
Company Outings
Game Room
In our Tempe, AZ office.
Stocked Kitchen
In our NYC and LA offices.
Some Meals Provided
Catered lunch three days per week in NYC and LA.
Happy Hours
In our NYC and LA offices.
Parking
For our Tempe, AZ office.
Recreational Clubs
Relocation Assistance
Fitness Subsidies
Professional Development Benefits
Job Training & Conferences
Diversity Program
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