[Hiring] Sr. Quality of Care Review Nurse @Oscar Health

Role Description

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.

About the role:

• Clinical Quality programs are designed to enhance clinical outcomes and concierge-level service to our members.
• The Senior Clinical Quality Nurse drives clinical performance through the quality auditing and clinical quality of care review process.
• Serves as a peer mentor and consultant, working collaboratively with team members to implement audit programs that reflect department goals and key performance indicators.
• Meets all regulatory and organizational requirements.

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

Work Location:

• This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; or Texas.
• Occasional travel may be required for team meetings and company events.

Pay Transparency:

• The base pay for this role is: $83,628 - $109,761.75 per year.
• You are also eligible for employee benefits, participation in Oscar's unlimited vacation program and annual performance bonuses.

Responsibilities

• 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.

Requirements

• Licensed Registered Nurse with active, unrestricted license in state of residence.
• 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.

Bonus Points

• Health plan utilization management experience or case management experience.
• Experience in healthcare quality assurance, including auditing medical records and evaluating clinical information.
• 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.
• 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.

Benefits

• Medical, dental, and vision benefits.
• 11 paid holidays.
• Paid sick time.
• Paid parental leave.
• 401(k) plan participation.
• Life and disability insurance.
• Paid wellness time and reimbursements.