Associate Medical Director, Utilization Management

About the role

The Associate Medical Director at Oscar Health is responsible for determining the medical appropriateness of a diverse range of services, including inpatient, outpatient, and pharmacy care. This position requires a deep dive into clinical information, where evidence-based guidelines are applied rigorously to form precise and defensible medical decisions. The role holds significant influence over departmental strategy, shaping the direction of utilization management initiatives. It mandates leadership and oversight of a team of physicians to guarantee efficient management, adherence to quality standards, and alignment with organizational goals. The Associate Medical Director reports directly to the Senior Medical Director, integrating their strategic vision into operational workflows. This position was established in 2012 with the specific purpose of creating the health insurance company the founders desired, embedding a member-first philosophy. The work demands a blend of clinical excellence and operational diligence to ensure that every decision reflects the highest standards of care. Ultimately, the role ensures that Oscar Health members receive care that is medically necessary, appropriate, and delivered with integrity.

Key facts

What you'll do

• Executing timely medical reviews that satisfy Oscar's stringent quality parameters and uphold the integrity of the decision-making process.
• Delivering clinical determinations based strictly on evidence-based criteria and Oscar internal guidelines and policies, ensuring consistency and compliance.
• Applying rigorous clinical acumen to every review decision to assess medical necessity and appropriateness with precision.
• Documenting all communication and decision-making clearly and accurately within Oscar workflow tools to maintain a reliable audit trail.
• Ensuring documentation maintains a Flesch-Kincaid grade level suitable for member understanding, promoting transparency and clarity.
• Using correct templates for documenting decisions during case reviews to standardize the review process and enhance accuracy.
• Receiving and reviewing escalated cases, conducting thorough analyses to resolve complex scenarios effectively.
• Conducting timely peer-to-peer discussions with treating providers to gather necessary information and align on clinical rationale.
• Clarifying review outcome decisions during provider conversations to ensure mutual understanding and resolve any discrepancies.
• Offering feedback on alternate treatment options based on medical necessity criteria and evidence-based research to optimize care pathways.
• Managing direct reports and overseeing their performance to foster a high-performing, accountable team environment.
• Providing oversight to ensure the team meets turnaround times for clinical reviews without compromising the quality of assessments.
• Collaborating with other departments on Utilization Management Operations to streamline processes and improve cross-functional efficiency.
• Leading key projects and driving initiatives to successful completion, ensuring strategic objectives are met on schedule and to standard.
• Fulfilling other duties as assigned, demonstrating flexibility and a commitment to the broader goals of the organization.
• Maintaining compliance with all applicable laws and regulations, ensuring that all practices adhere to legal and industry standards.

Requirements

• Holding board certification as an MD or DO, which is mandatory to demonstrate the highest level of medical expertise and professionalism.
• Maintaining a current unrestricted license to practice medicine, ensuring the candidate is fully authorized to practice without limitations.
• Accumulating 3+ years of clinical practice, providing a robust foundation in medical knowledge and patient care experience.
• Securing 2+ years of utilization review experience within a managed care plan in the healthcare industry, ensuring familiarity with the specific demands of utilization management.
• Licensure in multiple Oscar operating states is advantageous, broadening the scope of practice and operational flexibility.
• Experience with care management within the health insurance industry is beneficial, offering insights into the nuances of managed care environments.
• Willingness to obtain additional state licenses as business needs arise, with Oscar's support, is expected, reflecting a commitment to compliance and adaptability.
• A demonstrated ability to work independently and as part of a collaborative team, balancing autonomy with strong communication skills.
• Strong analytical and problem-solving skills are essential to navigate complex clinical scenarios and make sound decisions.
• A commitment to continuous learning and staying current with medical guidelines and best practices to ensure the highest standards of care.

Practical notes

This opportunity is presented as an authentic Oscar Health position. Individuals are encouraged to verify details. Oscar Health is an Equal Opportunity Employer.