• Apply clinical skills and expertise in conjunction with established medical criteria • Maintain a thorough and comprehensive understanding of regulations, payer contracts, product lines, NELC policies & procedures • Review clinical documentation for long term government payers twice a year • Act as a liaison between internal and external customers • Determine appropriateness and effectiveness of services requested • Responsible for timely and comprehensive medical review with concise documentation • Effectively communicate coverage decisions to members, providers, and medical groups • Identify and appropriately inform Manager/Supervisor of sensitive or complex cases • Develop and maintain positive working relationships with Medical Directors, physicians, vendors • Maintain confidentiality of member and case information

Role Description Hi, we're Oscar. We're hiring a Physician Reviewer to join our Utilization Management team. Oscar is the first health insurance company built around a full stack technology platform and a relentless 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 determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines. - Hours: 8am - 5pm in your local time zone - Call rotation - 1 weekend every 16 weeks - You will report into the Associate Medical Director, Utilization Management. - Work Location: This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; or Texas. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. #LI-Remote - Pay Transparency: The base pay for this role is: $211,200 - $277,200 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation, and annual performance bonuses. Responsibilities: - Provide timely medical reviews that meet Oscar's stringent quality parameters. - Provide clinical determinations based on evidence-based criteria and Oscar internal guidelines and policies, while utilizing clinical acumen. - Clearly and accurately document all communication and decision-making in Oscar workflow tools, ensuring a member could easily reference and understand your decision (Flesch-Kincaid grade level). - Use correct templates for documenting decisions during case review. - Meet the appropriate turn-around times for clinical reviews. - Receive and review escalated reviews. - Conduct timely peer-to-peer discussions with treating providers 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 - Board certification as an MD or DO. - Licensed in FL or NC and/or active Interstate Medical Licensure Compact (IMLCC) or eligible to apply for IMLCC. - 6+ years of clinical practice. - 1+ years of utilization review experience in a managed care plan (health care industry). Requirements - Licensure in multiple Oscar states (bonus points). - BC in Cardiology, Radiation/Oncology, or Neurology (bonus points). - Experience with care management within the health insurance industry (bonus points). - Willing and able to obtain additional state licensure as needed, with Oscar's support. Benefits - 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.

Role Description Carebridge LPN/LVN at CareBridge Health is responsible for the examination and treatment of patients under the direction of the physician. - Reviews patient medical records, interviews patients, and records vital signs. - Provides nursing interventions and coaching in accordance with the scope of practice and standing orders. - Facilitates patient transfers to alternate level of care as needed. - Documents using standard templates. - Ability to be on the phone engaging with patients up to 80% of the shift. - Ability to work assigned weekends per standard team rotation. - Reliable internet and a high level of customer service. Qualifications - Requires an LPN or LVN and a minimum of 2 years of experience as an LPN/LVN; or any combination of education and experience that would provide an equivalent background. - Current LPN/LVN license in the applicable state required. - Satisfactory completion of a Tuberculosis test is a requirement for this position. Requirements - Bi-lingual (English/Spanish) preferred. - Experience with Telephonic Triage preferred. - Acute care experience (e.g., urgent care or ER) preferred. Benefits - Comprehensive benefits package. - Incentive and recognition programs. - Equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

Overview Works with the Utilization Management team responsible for prior authorizations, inpatient and outpatient medical necessity/utilization review and other utilization management activities aimed at providing members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Mentors and trains new team members. Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. This position also trains and mentors new team members as well as assesses services for Sendero members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Utilizes clinical skills to review and monitor members' utilization of health care services with the goal of maintaining high quality cost-effective care for members that are hospitalized in acute, skilled and long-term care settings. Performs telephonic reviews of inpatient hospital admissions and assist with the coordination ofdischarge planning needs. Obtains the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs. Evaluates the options and services required to meet the member's health needs, in support and collaboration with disease management interventions. Performs prospective, concurrent & retrospective review of inpatient, outpatient, ambulatory & ancillary services requiring clinical review including all levels of appeal requests. Hours of operation are Monday through Friday 8 am to 5 pm to include extended hours that may occur on a weekend and/or holidays as required by State and Federal regulations in order to maintain operational compliance. This position is considered Remote, which means that individuals in this position may work at an approved Offsite location; however, they may be required to occasionally visit a Central Health office in Austin, Texas. Remote work not available for residents of California, Colorado, New York, New Jersey, Hawaii, Maryland, Montana, Pennsylvania, Virginia, or Washington. Responsibilities Essential Duties (at least 5 that are non-negotiable duties and are absolutely pertinent to successfully completing the job without accommodations): - Provides concurrent review and prior authorizations (as needed) according to policy. - Perform concurrent and retrospective reviews on all inpatient, facility and appropriate home health services. - Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures. - Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and cost. - Completes assigned work plan objectives and projects on a timely basis. - Collect pertinent documentation and conduct medical services review applying appropriate national standardized medical criteria, Sendero medical policy, and state and federal guidelines. - Perform discharge planning activities in coordination with facility or provider case manager. - Act as a member/family advocate in coordinating and accessing medical necessity of health care services within the benefit plan. - Consult with a Medical Director as appropriate for all requests requiring MD approval or not meeting criteria for approval. - Maintain open communication flow with to other care management staff to facilitate smooth transition and - follow-up as member is transitioned from one level of care and/or service to another. - Seek out opportunities to improve HEDIS, NCQA, URAC or general accreditation and QIA activities. - Perform other related tasks as assigned by supervisor or manager and maintains department productivity and quality measures. - Attends regular staff meetings, conducts self in a professional manner at all times, and completes assigned work objectives and projects in a timely manner. Knowledge/Skills/Abilities: - Knowledge of Managed Care principles and practices, involving medical and behavioral case management, disease management, utilization and pharmaceutical management. - Skilled with clinical knowledge and experience in the treatment of human injuries, diseases, and deformities including symptoms, treatment alternatives, drug properties and interactions, behavioral health conditions and preventive health guidelines. - Demonstrated ability to lead, communicate, problem solve, and work effectively with people. - Excellent organizational skill with the ability to manage multiple priorities. - Work independently and handle multiple projects simultaneously. - Knowledge of applicable state, and federal regulations. - In depth knowledge of InterQual and other references for length of stay and medical necessity determinations. - Subject matter expert with NCQA requirements. - Ability to take initiative and see tasks to completion. - Computer Literate (Microsoft Office Products). - Computer Literate (Microsoft Office Products). - Excellent verbal and written communication skills. - Ability to abide by Sendero’s policies. - Ability to maintain attendance to support required quality and quantity of work. - Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA). - Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers. Qualifications MINIMUM EDUCATION: High School Diploma or equivalent Required and Completion of an accredited (RN) or an accredited (LVN) program Required MINIMUM EXPERIENCE: One (1) year clinical practice experience Required AND Two (2) years managed care experience with utilization management and/or case management REQUIRED CERTIFICATIONS/LICENSURE: Holds and maintains these certifications as a professional. Lapsing/expiration of these certifications/licensure will result in suspension of work:1. Active, unrestricted State Registered Nursing license in good standing