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Insurance Utilization Reviewer Jobs in New York (NOW HIRING)

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Insurance Utilization Reviewer information

What is an insurance utilization reviewer?

Insurance Utilization Reviewers are professionals who evaluate healthcare services to determine if they are medically necessary and covered by insurance policies. They review patient records, treatment plans, and insurance guidelines to ensure that the care provided aligns with established criteria and standards. Their work helps control healthcare costs, prevent unnecessary treatments, and ensure patients receive appropriate care. Utilization reviewers often communicate with healthcare providers and insurance companies to support or deny coverage decisions.

What are the key skills and qualifications needed to thrive as an insurance utilization reviewer, and why are they important?

To thrive as an Insurance Utilization Reviewer, you need a solid understanding of medical terminology, healthcare regulations, and insurance processes, usually supported by a clinical background or relevant certification. Familiarity with utilization review software, electronic health records (EHRs), and coding systems like ICD-10 and CPT is often required. Strong analytical thinking, attention to detail, and effective communication skills help reviewers assess medical necessity and coordinate with healthcare providers. These skills ensure accurate, efficient case evaluations and compliance with policies, which are crucial for optimizing patient care and managing healthcare costs.

What are some common challenges faced by insurance utilization reviewers, and how can they be addressed?

One of the primary challenges Insurance Utilization Reviewers face is balancing the need to adhere to strict insurance guidelines while advocating for appropriate patient care. Reviewers often handle high caseloads and must make timely decisions based on complex medical records, which requires strong attention to detail and up-to-date knowledge of coverage policies. Effective communication with healthcare providers and insurance representatives is also crucial to resolve discrepancies and ensure approvals. Staying organized, continuously updating clinical knowledge, and leveraging support from the utilization review team can help manage these challenges successfully.

What is the difference between Insurance Utilization Reviewer vs Insurance Claims Processor?

AspectInsurance Utilization ReviewerInsurance Claims Processor
Primary RoleReview medical necessity and appropriateness of services for insurance coverageProcess and review insurance claims for payment and accuracy
Required CredentialsOften requires healthcare or insurance certifications, such as RHIT or CPCTypically requires claims processing or insurance certifications, like CPC or CPC-H
Work EnvironmentHealthcare settings, insurance companies, or third-party administratorsInsurance companies, healthcare providers, or claims processing centers
Industry UsageCommonly employed in health insurance and managed careWidely used across health, auto, and property insurance sectors

The main difference is that Insurance Utilization Reviewers focus on evaluating the medical necessity of services, while Insurance Claims Processors handle the administrative processing of claims. Both roles require insurance-related certifications and are integral to the insurance industry, but they serve distinct functions in the claims and coverage review process.

What are popular job titles related to Insurance Utilization Reviewer jobs in New York?

For Insurance Utilization Reviewer jobs in New York, the most frequently searched job titles are:

What job categories do people searching Insurance Utilization Reviewer jobs in New York look for?

The top searched job categories for Insurance Utilization Reviewer jobs in New York are:

What cities in New York are hiring for Insurance Utilization Reviewer jobs?

Cities in New York with the most Insurance Utilization Reviewer job openings:

Insurance Utilization Reviewer jobs near you

Associate Medical Director, Utilization Management

Oscar Health

New York, NY • Remote

$240K - $315K/yr

Full-time

Medical, Retirement, PTO

Posted 20 days ago

Oscar Health rating

6.9

Company rating: 6.9 out of 10

Based on 6 frontline employees who took The Breakroom Quiz

259th of 310 rated insurance

Job description

Hi, we're Oscar. We're hiring an Associate Medical Director to join our Utilization Management 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 ourselves-one that behaves like a doctor in the family.

About the role:

This role determines the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines. This role also influences departmental strategy, leading and overseeing a team of physicians ensuring efficient management and adherence to quality standards.

You will report into the Senior Medical Director.

Work Location: This is a remote position, open to candidates holding an active medical license in Florida, Arizona or North Carolina, OR to physicians who hold an IMLC compact license. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. #LI-Remote

Pay Transparency: The base pay for this role is: $240,120 - $315,157 annually. You are also eligible for employee benefits including a performance bonus, 401K with immediate vesting, and unlimited PTO. 

Responsibilities:

  • Provide timely medical reviews that meet Oscar's stringent quality parameters.

  • Provide clinical determinations based on evidence-based criteria and Oscar internal guidelines and policies, while utilizing clinical acumen.

  • Clearly and accurately document all communication and decision-making in Oscar workflow tools, ensuring a member could easily reference and understand your decision (Flesch-Kincaid grade level).

  • Use correct templates for documenting decisions during case review.

  • Receive and review escalated reviews.

  • Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research.

  • Manage direct reports and oversee their performance.

  • Provide oversight to ensure the team meets turn-around times for clinical reviews.

  • Collaborate with other departments on Utilization Management Operations.

  • Lead key projects and drive initiatives to successful completion.

  • Other duties as assigned

  • Compliance with all applicable laws and regulations.ocus on the main or important responsibilities))

Requirements:

  • Board certification as an MD or DO with a current unrestricted license to practice medicine is required.

  • 3+ years of clinical practice

  • 2+ years of utilization review experience in a managed care plan (health care industry)

Bonus points:

  • Licensure in multiple Oscar states

  • Experience with care management within the health insurance industry.

  • Willing and able to obtain additional state licensure as business needs, with Oscar's support

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