Sr. Quality of Care Review Nurse

Hi, we're Oscar. We're hiring a Sr. Quality of Care Review Nurse to join our Quality 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.

Clinical Quality programs are designed to enhance clinical outcomes and concierge-level service to our members, through review of services provided to members from network healthcare providers, facilities and Oscar employees. The Senior Clinical Quality Nurse drives clinical performance through the quality auditing and clinical quality of care review process for the departments they serve. The Clinical Quality Nurse serves as a peer mentor and a consultant, working collaboratively with team members to implement audit programs that reflect department goals and key performance indicators, meeting all regulatory and organizational requirements.

You will report into the Nurse Manager, Quality of Care.

• →Perform quality audits of internal and external member, provider and delegated vendor interactions; guide interrater reliability(IRR) assessments, supporting evidence-based clinical decision-making and workflow adherence
• →Investigate provider and facility quality of care concerns, identifying and escalating negative performance trends for corrective action
• →Consult with company partners to ensure that programs developed meet changing organizational needs while following accreditation and regulatory requirements
• →Present quality and performance trend data to organizational partners, delegates and quality subcommittees as applicable; Collaborate on corrective action plans to address identified gaps
• →Compliance with all applicable laws and regulations
• →Other responsibilities as assigned

• Licensed Registered Nurse with active, unrestricted license in state of residence and willingness to obtain additional licenses as needed for Oscar's growth (with Oscar's support)
• 2+ years of experience as a Registered Nurse
• 2+ years experience working in a clinical care setting

• Health plan utilization management experience or case management experience
• Experience in healthcare quality assurance, including experience auditing medical records and evaluating clinical information and internal documentation to determine the quality of care and service provided to members.
• Experience in health plan case management
• Bilingual - fluent in Spanish to audit Spanish-language verbal and written interactions
• Bachelor's Degree from an accredited university, BSN Preferred
• A working knowledge of health insurance/benefit concepts - Medicare and Individual Marketplace insurance experience a plus.
• Experience with NCQA accreditation standards for utilization management, case management or population health, HEDIS measures and other regulatory requirements
• CCM or MCG certification
• Experience analyzing performance and other forms of data
• Proficiency using Google applications like Sheets, Docs, Slides and Meets
• Comfortable using Google Meets and other platforms to communicate with internal/external partners