Manager, Clinical Policy

Miami, FL - USA

Yearly Salary: $ 131200 - 172200

Posted on: 03-11-2025

Vacancies: 1 Vacancy

Job Summary

Hi were Oscar. Were hiring a Manager Clinical Policy to join our Clinical Policy team.

Oscar is the first health insurance company built around a full stack technology platform and a focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselvesone that behaves like a doctor in the family.

About the role:

You will be a key member on our Clinical Policy team within the Office of Clinical Affairs (OCA). You will work regularly with cross-functional leaders to ensure our vended policy sets are driving affordability and clinical quality goals. You will oversee the clinical assessment of the policies themselves ensuring accuracy and validating the vendors process of development maintenance and implementation.

You will report to the Senior Manager Clinical Policy Development.

Work Location: This is a remote position open to candidates who reside in: Miami-Dade Metro area. You will be fully remote; however our approach to work may adapt over time. Future models could potentially involve a hybrid presence at the hub office associated with your metro area. #LI-Remote

Pay Transparency: The base pay for this role is: $131200 - $172200 per year. You are also eligible for employee benefits participation in Oscars unlimited vacation program and annual performance bonuses.

Responsibilities:

Clinically evaluate vendor policy sets to ensure their development and criteria meet internal and external standards for our medical policy referencing standards of care third-party criteria and other sources.
Vet newly identified vendor policy sets for affordability opportunities taking into account various factors including but not limited to policy & clinical departmental strategy & goals and organizational strategy & goals.
Ensure vendor policy and processes are streamlined standardized and adhere to larger departmental strategy.
Work with cross functional partners to support affordability initiatives involving other types of policy from a clinical standpoint and by using subject matter expertise and business acumen to advise and provide recommendations across the organization.
Support areas of efficiency improvement including in-housing analyses or projects.
Track all deliverables to ensure we are meeting SLAs and TAT. Develop SLAs and TAT where needed.
Prepare and present all materials for executive external view and feedback. Summarize changes and track evolution of vendor policy changes to support audit functions.
Responsible for high-complexity reviews that require extensive up-to-date industry expertise or contextual knowledge.
Develop an in-depth understanding of regulatory and quality requirements applicable to our programs.
Ensure processes and documentation are in place and in compliance with State Federal and NCQA requirements.
Provide support on regulatory audits and quality accreditation surveys as needed.
Compliance with all applicable laws and regulations
Other duties as assigned

Requirements:

Bachelors degree (minimum) in a relevant field of study specifically PA NP APRN BSN or RN is required.
Active unrestricted clinical license
4 years of direct work experience with clinical policy development or evaluation with an emphasis on health insurance policy.
4 years of work experience in utilization management and/or clinical operations.
3 years of experience communicating and presenting to stakeholders of all levels.
2 years of experience using Excel/Google Sheets and PowerPoint/Google Slides.
Working knowledge of medical coding (e.g. CPT ICD-10 HCPCS) and claims.

Bonus points:

Experience with commercial or ACA insurance.
Experience with managed care regulatory & compliance requirements.
Experience working in a fast-paced collaborative environment.
Experience translating between clinical and business vocabularies.
Experience in clinical pathways.
Familiarity with Managed Care Pharmacy

This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here.

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. Were on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives.

Pay Transparency: Final offer amounts within the base pay set forth above are determined by factors including your relevant skills education and experience. Full-time employees are eligible for benefits including: medical dental and vision benefits 11 paid holidays paid sick time paid parental leave 401(k) plan participation life and disability insurance and paid wellness time and reimbursements.

Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts.

Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications without regard to applicants disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team () to make the need for an accommodation known.

California Residents: For information about our collection use and disclosure of applicants personal information as well as applicants rights over their personal information please see our Notice to Job Applicants.

Required Experience:

Manager

Hi were Oscar. Were hiring a Manager Clinical Policy to join our Clinical Policy team.Oscar is the first health insurance company built around a full stack technology platform and a focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want fo...