Utilization Review Nurse

Oscar

Utilization Review Nurse conducting case reviews and assessing medical necessity for Oscar Health. Collaborating with care providers and ensuring compliance with guidelines.

Posted 6/24/2026full-timeRemote • Arizona, Florida, Illinois, Iowa, Kansas, Missouri, Montana, New Jersey, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia • 🇺🇸 United StatesJunior💰 $35 - $46 per hourWebsite

About the role

Key responsibilities & impact

Perform frequent case reviews and check medical records
Speak with care providers regarding treatment as needed
Make recommendations regarding appropriateness of care for identified diagnoses based on research results
Report into the Supervisor, Utilization Review
Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and Oscar Clinical Guidelines, Milliman Care Guidelines
Obtain information necessary (via telephone and fax) to assess a member's clinical condition, and apply the appropriate evidence-based guidelines
Meet required decision-making SLAs
Refer members for further care engagement when needed
Compliance with all applicable laws and regulations
Other duties as assigned

Requirements

What you’ll need

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 Diploma Program in Practical Nursing of 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 utilizating MCG (Milliman Care Gudielines)
1+ years of clinical experience (including at least 1+ year clinical practice in an acute care setting, i.e., ER or hospital)

Benefits

Comp & perks

Employee benefits
Monthly vacation accrual at a rate of 15 days per year

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

utilization reviewclinical judgmentmedical necessity reviewslevel of care reviewsevidence-based guidelinesMCGacute care experiencecase reviewsmedical record assessment

Soft Skills

communicationdecision-makingrecommendation skillsinterpersonal skills

Certifications

RN licensureAssociate Degree - NursingDiploma Program in Practical Nursing