Clinicians need ranking systems that work in real time and still justify their choices. Motivated by the need for a low-latency, decoder-based reranker, we present OG-Rank, a single-decoder approach that pairs a pooled first-token scoring signal with an uncertainty-gated explanation step. The model scores all candidates in one pass and generates a brief, structured rationale only when the list is genuinely ambiguous, keeping latency predictable. Trained with a curriculum that concentrates effort on hard cases, OG-Rank delivers strong effectiveness on encounter-scoped order selection (fast path: Recall@1~0.45, nDCG@20~0.625) and improves further when the gate activates (Recall@1~0.56, nDCG@20~0.699 at a 45\% gate rate), while compact backbones show similar gains under the same policy. Encoder baselines trail in both effectiveness and flexibility. The result is a practical recipe: rank fast by default and explain when it helps, a pattern that applies broadly to decision tasks where selective generation buys accuracy at acceptable cost. The single-policy design simplifies deployment and budget planning, and the curriculum principle (spend more on the hard cases, less on the easy ones) readily transfers beyond clinical order selection.

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