Remote Utilization Management Physician

CVS Health; Chicago (IL); Remote; USD 207,000 - 253,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

Oak Street Health seeks a Utilization Management Physician Reviewer to ensure timely coverage determinations for inpatient and outpatient services using UM criteria and clinical judgment. The role collaborates with internal teams to promote quality care, adherence to CMS/MCG guidelines, and regulatory compliance.

The ideal candidate is board-certified with an unrestricted US license, 3–5 years in primary care, and a strong foundation in managed care and patient advocacy.

Qualifications

• One year of UM experience for Medicare/Medicaid line of business.
• Strong verbal and written communication skills.
• Current unrestricted medical license in the US (NCQA standard).
• Graduate of an accredited medical school (MD or DO).
• 3–5 years of clinical practice in a primary care setting.
• Deep understanding of managed care concepts and care coordination.
• Active participation in continuing education to maintain licensure.
• Demonstrated understanding of culturally responsive care.
• Strong organizational and detail-oriented skills.
• US work authorization.

Responsibilities

• Review service requests and document rationale per Oak Street Health policies and industry standards.
• Apply evidence-based criteria with clinical judgment for UM determinations.
• Collaborate with Transitional Care and PCP teams to improve care delivery.
• Maintain knowledge of CMS and MCG guidelines for UM decisions.
• Ensure compliance with regulatory and accreditation requirements.
• Participate in UM initiatives and committees to improve quality.
• Assist in responses to payor UM process inquiries.
• Fulfill on-call duties as needed.
• Perform other duties as assigned.

Skills

UM experience

Strong communication

Medical license US

MD/DO degree

Clinical practice 3-5 yrs

Managed care knowledge

Continuing education

Culturally responsive care

Organizational skills

US work authorization

Oaky values

Education

MD/DO from accredited medical school

Job description

Oak Street Health seeks a Utilization Management Physician Reviewer to ensure timely coverage determinations for inpatient and outpatient services using UM criteria and clinical judgment. The role collaborates with internal teams to promote quality care, adherence to CMS/MCG guidelines, and regulatory compliance.

The ideal candidate is board-certified with an unrestricted US license, 3–5 years in primary care, and a strong foundation in managed care and patient advocacy.