Physician Reviewer – Utilization Management

Oscar Health

. Determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines .

Posted 11/3/2026full-timeRemote • United StatesMid-LevelSenior💰 $275,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical appropriateness determination for inpatient and outpatient services, utilizing evidence-based guidelines and clinical acumen. Proficient in documentation and communication within workflow tools, ensuring compliance with laws and regulations.

Highest-signal resume keywords

Board Certification As An MD Or DOUtilization Review ExperienceClinical Practice ExperienceEvidence-Based Guidelines ApplicationActive Medical Licensure In Florida, North Carolina, Or Arizona

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical DeterminationMedical Necessity CriteriaPeer-To-Peer DiscussionsCare ManagementQuality Parameters ReviewDocumentation In Workflow ToolsEvidence-Based Research ApplicationEscalated Review HandlingTurnaround Time ManagementAlternate Treatment Feedback

Soft Skills

CommunicationDecision-MakingCollaboration

Tools & Technologies

Oscar Workflow Tools

Certifications & Qualifications

Board Certification In CardiologyBoard Certification In Radiation/OncologyBoard Certification In NeurologyInterstate Medical Licensure Compact (IMLC)

Industry Keywords

Managed Care PlanHealth Insurance IndustryClinical Information ReviewInpatient ServicesOutpatient ServicesPharmacy ServicesClinical AcumenApplicable Laws And Regulations

About the role

Key responsibilities & impact

Determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines
Provide medical reviews meeting Oscar's quality parameters
Provide clinical determinations based on evidence-based criteria, internal guidelines, policies, and clinical acumen
Document communications and decision-making in Oscar workflow tools using correct templates
Meet turnaround times for clinical reviews
Receive and review escalated reviews
Conduct peer-to-peer discussions with treating providers to clarify clinical information and explain review outcomes
Provide feedback on alternate treatment based on medical necessity criteria and evidence-based research
Comply with applicable laws and regulations
Perform other duties as assigned
Report to the Associate Medical Director, Utilization Management
Participate in a call rotation of one weekend every 16 weeks

Requirements

What you’ll need

Board certification as an MD or DO
Licensed in Florida, North Carolina, or Arizona, or possess an active Interstate Medical Licensure Compact (IMLC)
6+ years of clinical practice
Willing and able to obtain additional state licensure as needed, with Oscar's support
Licensure in multiple Oscar states is a bonus
1+ years of utilization review experience in a managed care plan is a bonus
Board certification in Cardiology, Radiation/Oncology, or Neurology is a bonus
Experience with care management within the health insurance industry is a bonus

Benefits

Comp & perks

Employee benefits
Oscar's unlimited vacation
Annual performance bonuses
Medical benefits
Dental benefits
Vision benefits
11 paid holidays
Paid sick time
Paid parental leave
401(k) plan participation
Life and disability insurance
Paid wellness time and reimbursements
Oscar's support to obtain additional state licensure as needed