Manager, Medical Policy

Dallas, IA - USA

Yearly Salary: $ 131200 - 172200

Posted on: 4 hours ago

Vacancies: 1 Vacancy

Job Summary

Hi were Oscar. Were hiring a Manager Medical Policy to join our Medical Policy 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 ourselvesone that behaves like a doctor in the family.

About the role:

You will lead the clinical research and development of evidence-based medical necessity criteria within the Office of Clinical Affairs (OCA). You will be responsible for the end-to-end clinical lifecycle of medical policies ensuring that coverage criteria for medical services devices and technologies are supported by current clinical literature and nationally recognized standards. You will serve as the lead clinical subject matter expert (SME) for medical evidence appraisal ensuring our clinical policies are evidence-based compliant and supportive of optimal health outcomes for Plan members.

You will report into the Associate Director Clinical Policy - Affordability.

Work Location:This is a remote position open to candidates who reside in: Dallas TX. 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:

Lead the review of clinical literature regulating agency guidance (e.g. FDA CMS State/Federal Departments) and specialty society guidelines to develop sound coverage criteria for medical services devices and technologies.
Conduct and manage health technology assessments for novel medical technologies and complex devices.
Coordinate with internal and external specialty-matching physicians for the clinical review and validation of medical policies.
Translate complex clinical data and evidence-based recommendations into precise defensible medical necessity criteria and clinical positions or guidance.
Own the end-to-end drafting and maintenance of the medical policy library ensuring language is clinically accurate unambiguous and operationally interpretable.
Responsible for the preparation and presentation of evidence-based medical policies and summaries of changes to the Clinical Advisory Subcommittee (CAS) and internal forums.
Oversee onboard develop and manage a team of clinical FTEs contractors and matrixed reports.
Ensure all clinical policy development processes are streamlined and align with the larger departmental and Office of Clinical Affairs (OCA) strategy.
Ensure clinical policy development processes and documentation comply 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:

Graduate degree in Healthcare Administration Public Health Health Policy Health Services Research Epidemiology or a closely related discipline (such as Nursing or another allied health field).
58 years in healthcare with 35 years specifically focused on medical policy development clinical research or medical writing.
Experience in people leadership including the ability to manage mentor and develop clinical professionals.
Proficiency in leveraging clinical databases (e.g. PubMed) to conduct literature reviews evaluate evidence and synthesize findings into defensible medical necessity criteria or recommendations.
Expert ability to interpret complex clinical data and conduct health technology assessments to determine medical coverage standards.

Bonus points:

Active unrestricted clinical license (e.g. RN NP PA).
Working knowledge of medical coding (e.g. CPT ICD-10 HCPCS) and claims.
2 years of experience using Excel/Google Sheets and PowerPoint/Google Slides.
Ability to translate technical clinical evidence for both clinical and non-clinical stakeholders.
Experience with Managed Care regulatory requirements NCQA standards and ACA marketplace rules.
Background in managed care utilization management or evidence-based clinical guideline development.
Experience in fast-paced tech-enabled environments with complex cross-functional stakeholder management.

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.

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Required Experience:

Manager

Hi were Oscar. Were hiring a Manager Medical Policy to join our Medical Policy 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 woul...