Manager, Clinical Policy

Manager, Clinical Policy

Oscar is the first health insurance company built around a full stack technology platform and a focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselvesone that behaves like a doctor in the family.

About the Role

You will be a key member on our Clinical Policy team within the Office of Clinical Affairs (OCA). You will work regularly with cross-functional leaders to ensure our vended policy sets are driving affordability and clinical quality goals. You will oversee the clinical assessment of the policies themselves ensuring accuracy, and validating the vendor's process of development, maintenance, and implementation. You will report to the Senior Manager, Clinical Policy Development.

Work Location

This is a remote position, open to candidates who reside in : Atlanta, Georgia. You will be fully remote; however, our approach to work may adapt over time. Future models could potentially involve a hybrid presence at the hub office associated with your metro area.

Pay Transparency

The base pay for this role is : $131,200 - $172,200 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program and annual performance bonuses.

Responsibilities

Clinically evaluate vendor policy sets to ensure their development, and criteria meet internal and external standards for our medical policy, referencing standards of care, third-party criteria, and other sources.

Vet newly identified vendor policy sets for affordability opportunities taking into account various factors, including, but not limited to, policy & clinical departmental strategy & goals, and organizational strategy & goals.

Ensure vendor policy and processes are streamlined, standardized, and adhere to larger departmental strategy.

Work with cross functional partners to support affordability initiatives involving other types of policy from a clinical standpoint and by using subject matter expertise and business acumen to advise and provide recommendations across the organization.

Support areas of efficiency improvement, including in-housing analyses or projects.

Track all deliverables to ensure we are meeting SLAs and TAT. Develop SLAs and TAT where needed.

Prepare and present all materials for executive external view and feedback. Summarize changes and track evolution of vendor policy changes to support audit functions.

Responsible for high-complexity reviews that require extensive up-to-date industry expertise or contextual knowledge.

Develop an in-depth understanding of regulatory and quality requirements applicable to our programs.

Ensure processes and documentation are in place and in compliance with State, Federal and NCQA requirements.

Provide support on regulatory audits and quality accreditation surveys, as needed.

Compliance with all applicable laws and regulations

Other duties as assigned

Requirements

Bachelor's degree (minimum) in a relevant field of study, specifically PA, NP, APRN, BSN, or RN, is required.

Active, unrestricted clinical license

4+ years of direct work experience with clinical policy development or evaluation, with an emphasis on health insurance policy.

4+ years of work experience in utilization management and / or clinical operations.

3+ years of experience communicating and presenting to stakeholders of all levels.

2+ years of experience using Excel / Google Sheets and PowerPoint / Google Slides.

Working knowledge of medical coding (e.g. CPT, ICD-10, HCPCS) and claims.

Bonus Points

Experience with commercial or ACA insurance.

Experience with managed care regulatory & compliance requirements.

Experience working in a fast-paced, collaborative environment.

Experience translating between clinical and business vocabularies.

Experience in clinical pathways.

Familiarity with Managed Care Pharmacy