Join Oscar Health as a Senior UM Review Nurse, a critical role driving the company's mission to revolutionize healthcare by making it accessible, affordable, and transparent. In this position, you will leverage your clinical expertise to oversee utilization management processes, ensuring members receive appropriate care while optimizing costs and outcomes. Your work directly impacts thousands of lives, supporting Oscar's innovative tech-driven approach to health insurance that empowers better health decisions. As a Senior UM Review Nurse, your day-to-day involves conducting thorough clinical reviews of member cases, assessing medical necessity using evidence-based guidelines like MCG or InterQual. You will daily evaluate prior authorizations, concurrent reviews, and appeals, collaborating closely with physicians, care teams, and provider networks to approve, deny, or modify requests efficiently. Weekly, you analyze utilization trends, prepare reports on denial rates and turnaround times, and mentor junior nurses on complex cases. Monthly responsibilities include participating in interdisciplinary team meetings, updating review criteria based on regulatory changes, and contributing to quality improvement projects that track metrics such as approval rates above 95% and appeals overturned under 10%. You will manage a caseload of 50-70 reviews per week, ensuring all decisions are documented accurately in Oscar's proprietary claims platform, while fostering partnerships with external stakeholders like hospitals and specialists to streamline care delivery. To succeed, you need an active RN license, a BSN or higher, and at least 5 years of clinical nursing experience with 3+ years in utilization management or case management. Certification as a Certified Case Manager (CCM) or Certified Utilization Review Nurse is required, along with deep knowledge of Medicare, Medicaid, and commercial payer guidelines. Proficiency in EHR systems, Microsoft Office, and UM software is essential, complemented by strong analytical skills to interpret clinical data and payer policies accurately. Key skills include exceptional clinical judgment to navigate complex patient scenarios, superior communication for articulating decisions to diverse audiences, and attention to detail for compliance with HIPAA and NCQA standards. You should excel in time management to meet SLAs, demonstrate empathy in member interactions, and possess leadership abilities to train teams and drive process improvements in a fast-paced environment. Oscar Health is a tech-powered health insurer founded in 2012, with a mission to make healthcare simple and human-centered. Our 2,000+ employees thrive in a collaborative, inclusive culture emphasizing innovation, diversity, and work-life balance. Remote-friendly with core hours for team syncs, we offer a dynamic environment where your ideas shape the future of health tech. Compensation is competitive, though specific salary details are not specified; expect comprehensive benefits including medical, dental, vision coverage, 401(k) matching, unlimited PTO, and parental leave. Enjoy perks like wellness stipends, stock options, learning budgets, and flexible remote work arrangements to support your professional and personal growth. Advance your career through mentorship programs, leadership tracks into UM management, and ongoing training in emerging healthcare tech. Apply today via our careers portal to join a team transforming lives.