Clinical Quality RN

Hi, we're Oscar. We're hiring a Clinical Quality Registered Nurse to join our Quality 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 ourselves—one that behaves like a doctor in the family.

About the role

You will drive clinical performance through the quality auditing process for the departments you serve.

You will works collaboratively with stakeholders to implement audit programs that reflect department business objectives and key performance indicators, meeting all regulatory and organizational requirements. 

Clinical Quality programs are designed to enhance clinical outcomes and concierge-level service to our members.

You will report to the Manager, Clinical Programs.

Work Location:

Oscar is a blended work culture where everyone, regardless of work type or location, feels connected to their teammates, our culture and our mission.

If you live within commutable distance to our New York City office (in Hudson Square), our Tempe office (off the 101 at University Dr), or our Los Angeles office (in Marina Del Rey), you will be expected to come into the office at least two days each week. Otherwise, this is a remote / work-from-home role.

You must reside in one of the following states: Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, or Washington, D.C. Note, this list of states is subject to change. #LI-Remote

Pay Transparency:

The base pay for this role is: $72,800 - $95,550 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program, and annual performance bonuses.

Responsibilities

• Perform quality audits on clinical documentation, including member, provider and facility interactions for clinicians and providers from a variety of clinical departments. Develop audit surveys and rubrics to ensure the transparency of audit requirements, supporting evidence-based clinical decision making and adherence to department workflows and align with regulatory accreditation requirements.
• Pull clinician and provider cases and calls for auditing purposes, tracking results in department systems and tracking mechanisms.
• Support organizational readiness and preparation for NCQA and other regulatory audits
• Perform delegate oversight audits, writing audit result summary reports and presenting to stakeholders and delegates. Collaborate with leadership to develop corrective action plans to address identified gaps.
• Provide 1:1 feedback and coaching to front-line staff and leaders regarding departmental workflows and audit requirements and support developing training tools on quality best practices, audit standards and other topics as directed
• Collaborate with clinical training and department leadership/stakeholders regarding audit trends, process changes and training needs.
• Delivering quality-oriented presentations for large and small groups
• Aggregate quality data to identify and report performance trends to organizational stakeholders
• Participate in audit calibration sessions with internal staff and stakeholders to ensure audit consistency
• Participate in the interrater reliability process (IRR) as needed to support consistent clinical decision making across teams.
• Compliance with all applicable laws and regulations 
• Other duties as assigned 

Qualifications

• Licensed Registered Nurse with active, unrestricted license in state of residence and willingness to obtain additional licenses as needed for Oscar’s growth (with Oscar’s support)
• 2+ years of experience as a Registered Nurse 
• 1+ years experience working in a clinical care setting

Bonus Points

• Health plan utilization management experience, working knowledge of MCG criteria strongly preferred.
• Experience in healthcare quality assurance
• 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.
• Strong understanding of NCQA accreditation standards for utilization management, case management or population health, HEDIS measures and other regulatory requirements
• CCM or MCG certification
• Experience analyzing and interpreting 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 stakeholders