UM Nurse Manager

Oscar Health•Tempe, AZ

6d•Remote

About The Position

You will play a key role in driving clinical and operational performance within your department by ensuring all department activities are carried out in a clinically appropriate manner in accordance with organizational processes and evidence-based resources. You will interact frequently with direct reports, providers, external and internal stakeholders to review clinical services provided to Oscar members for clinical appropriateness and adherence to organizational and regulatory requirements. You will partner with key contacts across the organization, effectively communicating results and recommendations for improvement across disciplines. You will grow clinical teams through the direct leadership of leaders and front-line staff, playing a key role in driving the achievement of department quality and productivity metrics, goals and KPIs. The You will subject matter expertise, clinical knowledge, communication and problem-solving skills to address escalated issues. You will report into the Associate Director, Utilization Review. Work Location: This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; Illinois; Iowa; Kansas; Michigan; Missouri; Nebraska; New Jersey; North Carolina; Ohio; Oklahoma; Pennsylvania; South Carolina; Tennessee; Texas; or Virginia. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events.

Requirements

Bachelor's degree or 4+ years commensurate experience
Active, unrestricted Nursing license (RN) in the state of hire and ability to obtain additional licensure as needed
4+ years of experience in a healthcare setting as a nurse
2+ years of experience in utilization management making clinical decision using milliman care guidelines
1+ years of experience working in production/operations including case prioritization/case triage
2+ years leading a clinical team at a managed care plan or healthcare organization including in a virtual environment

Nice To Haves

Experience performing quality of care investigations or quality auditing or compliance oversight for a healthcare organization.
Proficiency using case ticketing systems e.g. Jira or Appian to prioritize & document team activities.
1+ years leading and/or implementing process improvement initiatives/Six Sigma or large scale projects
Strong proficiency in creating and working with Google Sheets, Slides, Docs and using applications to create presentations to stakeholders, and senior leadership.
Experience in communicating with senior leadership in a live (virtually or in-person) setting or via email- electronic communication.
Strong computer literacy, able to work effectively in multiple platforms
Experience leading employees and presenting to large groups in a virtual environment.
Working knowledge of NCQA and state/federal regulatory requirements for the areas served by the team

Responsibilities

Play a key role and provide input in creating and maintaining, based on regulatory, accreditation, and organizational requirements, policies and procedures defining the completion of all department functions to help ensure they meet the needs of our members, providers and internal/external stakeholders.
Oversee daily operations to ensure team work assignments are completed within established turnaround times and in accordance with department policies and procedures, regulatory and accreditation requirements.
Monitor team dashboards, review and analysis of productivity reporting, completion of quality audits and other data to monitor individual and team performance.
Maintain expertise on department tools and platforms to inform analysis.
Analyze data to identify performance trends/opportunities for improvement and work with data analytics regularly to ensure productivity and quality data provides actionable insights on team/individual performance against goals.
Create corrective action plans or performance improvement plans to address identified opportunities.
Drive a culture of accountability and recognition that aligns with department objectives and increases employee engagement.
Provide coaching, development and performance management to frontline staff and leaders, evaluating performance against goals throughout the year.
Compliance with all applicable laws and regulations
Other duties as assigned