What are the responsibilities and job description for the Clinical Appeals Liaison (Remote) position at Oscar Health?
Hi, we're Oscar. We're hiring a Clinical Appeals Liaison to join our Clinical Review 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:
This role will be accountable for processing clinical appeals for Oscar individual market lines. The role includes intake, assessment, and coordination of appeals, as well as liaising with various external agencies including state regulators and other third parties responsible for health plan administration and Oscar's internal Clinical Review Team. This role is responsible for assessing the eligibility of the appeals, gathering case documentation and medical records, and ensuring that we meet the requested or established timeframe requirements.
You will report into the Senior Nurse Lead. This is a remote / work-from-home role. You must reside in one of the following states: Arizona, California, Connecticut, Florida, Georgia, Illinois, Maryland, Massachusetts, Michigan, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Virginia, or Washington. Note, this list of states is subject to change.
Responsibilities:
- Assess incoming requests and inquiries for appeals, swiftly determining next steps and taking appropriate action
- Timely and comprehensive resolution, abiding by internal SLAs as well as stated mandated turnaround times
- Conduct a comprehensive review of case history and identify key elements, arguments and mitigating factors
- Outreach to providers for medical records and to members as needed to gather details relevant to the appeals
- Build tickets and gather case documents. Provide clear and accurate documentation in the ticketing system as to the progress and status of your work.
- Oversight and ownership of casework and timelines
- Establish a strong rapport with the Clinical and CGA Teams; escalating and coordinating with clinical staff where needed
- Escalation and coordination with the CGA staff when cases must be referred to the complaints, appeals and/or regulator teams
- Work as a team to complete departmental tasks to meet deadlines and accomplish department objectives. This may include evenings, weekends and holidays
Requirements:
- 2 years healthcare experience (clinical practice in an outpatient or acute care setting) or working with health plans, coordinating care, authorizations and/or appeals
- Knowledge of insurance industry and regulatory compliance to applicable state and federal laws
Bonus points:
- Bachelor's Degree
- Strong proficiency navigating and working in multi-system environment (customer service, case management, claims)
Life at Oscar:
At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care - an experience made whole by our unique backgrounds and perspectives.
We aim to make health care affordable and accessible for all, and apply this same vision to our perks and benefits, including: medical benefits, generous paid-time off, paid parental leave, retirement plans, company social events, stocked kitchens, wellness programs, and volunteer opportunities.
Reasonable Accommodation:
Oscar applicants are considered solely based on their qualifications, without regard to applicant's disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known.
Pay Transparency Policy:
Oscar ensures that you won't be discharged or discriminated against based on whether you've inquired about, discussed, or disclosed your pay. Read the full policy here.
COVID-19 vaccine requirements for in-person work:
To protect the health and safety of our employees, we require any employee conducting in-person work* to be fully vaccinated against COVID-19 by their start date. If you are unable to be vaccinated due to medical or protected religious reasons, please reach out to our Benefits team at accommodations@hioscar.com to submit an accommodations request.
- Note: In-person work includes: employees required to work from our offices, employees conducting sales work in the field and employees conducting at-home or in-person visits with members.
