Join Oscar Health as a UM Nurse Manager and play a pivotal role in revolutionizing healthcare delivery through innovative utilization management (UM) strategies. In this leadership position, you will oversee clinical review processes that ensure members receive timely, appropriate, and cost-effective care, directly impacting the company's mission to make high-quality healthcare accessible and affordable for all. Your expertise will help scale Oscar's tech-enabled platform, supporting thousands of members nationwide while fostering a culture of continuous improvement and patient-centered outcomes. As UM Nurse Manager, your day-to-day involves leading a team of utilization review nurses in conducting medical necessity reviews, prior authorizations, and concurrent reviews for inpatient, outpatient, and pharmacy services. Daily tasks include triaging complex cases, providing clinical guidance on evidence-based guidelines, and monitoring turnaround times to meet regulatory standards like NCQA and CMS. Weekly, you will analyze UM metrics such as approval/denial rates, appeal volumes, and cost savings, generating reports for senior leadership and adjusting workflows to optimize efficiency. Monthly responsibilities encompass team training on updated policies, auditing case documentation for compliance, and collaborating with medical directors, providers, and cross-functional teams in care management, provider relations, and data analytics to refine processes. You will manage performance evaluations, mentor staff on clinical decision-making, and spearhead quality improvement projects, such as reducing avoidable utilization by 15% through targeted interventions. Expect to handle escalations, participate in interdisciplinary rounds, and contribute to policy development, ensuring all activities align with Oscar's value-based care model. To succeed, candidates must hold an active RN license, a BSN or higher (MSN preferred), and 5+ years of clinical nursing experience with at least 3 years in utilization management or case management. Certification as a Certified Case Manager (CCM) or Certified Utilization Review Coordinator (CURC) is required, along with deep knowledge of InterQual or Milliman Care Guidelines, Medicare/Medicaid regulations, and HIPAA compliance. Proficiency in EHR systems like Epic, UM software platforms such as Zeus or Medecision, and Microsoft Office Suite is essential. Prior supervisory experience leading clinical teams in a fast-paced health plan environment is critical, with demonstrated success in managing high-volume reviews and achieving audit scores above 95%. Essential skills include strong clinical assessment abilities to evaluate complex cases swiftly, expertise in evidence-based medicine, and proficiency with UM tools and analytics platforms for data-driven decisions. Soft skills such as exceptional communication for stakeholder interactions, leadership to inspire and develop nursing teams, and problem-solving to navigate regulatory challenges are vital. You should excel in multitasking under pressure, fostering collaboration across departments, and promoting a culture of empathy and innovation in healthcare delivery. Oscar Health is a technology-driven health insurer on a mission to engineer healthier lives at lower costs, serving over 1 million members with a member-first approach. Our diverse, remote-friendly teams thrive in a collaborative, inclusive culture that values transparency, agility, and bold ideas, supported by cutting-edge tech like AI-powered care navigation. With offices in New York and nationwide, we offer a dynamic environment where your contributions directly shape the future of healthcare. We offer competitive compensation (salary not specified), comprehensive health benefits including medical, dental, and vision coverage, 401(k) matching, and generous PTO with flexible remote work options. Enjoy perks like wellness stipends, parental leave, stock options, and professional development budgets to support your growth in a high-impact role. Advance your career with clear paths to senior leadership in clinical operations or population health, plus ongoing training, conferences, and mentorship programs. Apply today via our careers portal to join Oscar Health and make a lasting impact.