Manager, Clinical Policy

Join to apply for the Manager, Clinical Policy role at Oscar Health . Hi, we're Oscar. We're hiring a Manager, Clinical Policy to join our Clinical Policy 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 be a key member of our Clinical Policy team within the Office of Clinical Affairs (OCA). You will work regularly with cross‑functional leaders to ensure our vended policy sets drive affordability and clinical quality goals. You will oversee the clinical assessment of policies, ensuring accuracy, and validate the vendor's development, maintenance, and implementation processes. You will report to the Senior Manager, Clinical Policy Development. Work Location This is a remote position, open to candidates who reside in the Greater Hartford area. The role is fully remote, though future work models may involve hybrid presence at the local hub office. Pay Transparency The base pay for this role is $131,200 – $172,200 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation program and annual performance bonuses. Responsibilities Clinically evaluate vendor policy sets to ensure their development and criteria meet internal and external standards for our medical policy, referencing standards of care, third‑party criteria, and other sources. Vet newly identified vendor policy sets for affordability opportunities taking into account various factors, including policy & clinical departmental strategy and goals, and organizational strategy. Ensure vendor policy and processes are streamlined, standardized, and adhere to larger departmental strategy. Work with cross‑functional partners to support affordability initiatives involving other policy types from a clinical standpoint, advising and providing recommendations across the organization. Support areas of efficiency improvement, including in‑housing analyses or projects. Track all deliverables to ensure we are meeting SLAs and TAT. Develop SLAs and TAT where needed. Prepare and present materials for executive external view and feedback. Summarize changes and track evolution of vendor policy changes to support audit functions. Responsible for high‑complexity reviews that require extensive up‑to‑date industry expertise or contextual knowledge. Develop an in‑depth understanding of regulatory and quality requirements applicable to our programs. Ensure processes and documentation are in place and 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 Bachelor's degree (minimum) in a relevant field of study, specifically PA, NP, APRN, BSN, or RN. Active, unrestricted clinical license. 4+ years of direct work experience with clinical policy development or evaluation, with an emphasis on health insurance policy. 4+ years of work experience in utilization management and/or clinical operations. 3+ years of experience communicating and presenting to stakeholders of all levels. 2+ years of experience using Excel/Google Sheets and PowerPoint/Google Slides. Working knowledge of medical coding (e.g., CPT, ICD‑10, HCPCS) and claims. Bonus Points Experience with commercial or ACA insurance. Experience with managed care regulatory & compliance requirements. Experience working in a fast‑paced, collaborative environment. Experience translating between clinical and business vocabularies. Experience in clinical pathways. Familiarity with Managed Care Pharmacy. Equal Opportunity Employer At Oscar, being an Equal Opportunity Employer means more than upholding discrimination‑free hiring practices. It means we cultivate an environment where people can be their most authentic selves and find both belonging and support. We’re on a mission to change health care—a experience made whole by our unique backgrounds and perspectives. 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 applicant’s disability or need for accommodation. If you require reasonable accommodations during the application process, please contact the Oscar Benefits Team at View email address on click.appcast.io. California Residents For information about our collection, use, and disclosure of applicants’ personal information, and applicants’ rights, see our Notice to Job Applicants. — Oscar Health #J-18808-Ljbffr Oscar Health