Remote Utilization Management Physician

CVS Health; Illinois; Hybrid; USD 207,000 - 253,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

Oak Street Health is seeking a full-time Utilization Management Physician Reviewer to determine inpatient and outpatient coverage using UM criteria, clinical judgment, and internal policies. This role requires coordination with care teams to ensure appropriate care and timely determinations to support optimal patient outcomes.

Qualified candidates will hold an MD/DO, have 1+ year UM experience in Medicare/Medicaid, demonstrate excellent communication, and possess US work authorization.

Qualifications

• At least one year experience providing Utilization Management services to a Medicare and/or Medicaid line of business.
• Excellent verbal and written communication skills.
• A current, clinical, unrestricted license to practice medicine in the United States.
• Graduate of an accredited medical school. MD or DO required.
• 3-5 years of clinical practice in a primary care setting.
• Deep understanding of managed care, risk arrangements, capitation, peer review, performance profiling, outcome management, care coordination, and pharmacy management.
• Strong record of continuing education activities relevant to practice area and licensure.
• Demonstrated understanding of culturally responsive care.
• Proven organizational and detail-orientation skills.
• US work authorization.
• Someone who embodies being Oaky.

Responsibilities

• Review service requests and document the rationale for the decision per Oak Street Health policies and industry standards.
• Use evidence-based criteria and clinical reasoning to make UM determinations.
• Work with Transitional Care and PCP teams to drive efficient care delivery.
• Maintain knowledge of CMS and MCG guidelines for UM decisions.
• Maintain compliance with regulatory and accreditation requirements and payor partner policies.
• Participate in UM improvement initiatives and committees.
• Assist in responses to health plans regarding UM processes or determinations.
• Adhere to regulatory requirements of payor partners.
• Participate in rounding and patient panel management discussions.
• Fulfill on-call requirements as needed.
• Other duties as assigned.

Skills

Utilization Management

Verbal & written communication

Licensed physician

Primary care experience

Cultural competency

Organizational skills

Education

MD/DO degree

Job description

Oak Street Health is seeking a full-time Utilization Management Physician Reviewer to determine inpatient and outpatient coverage using UM criteria, clinical judgment, and internal policies. This role requires coordination with care teams to ensure appropriate care and timely determinations to support optimal patient outcomes.

Qualified candidates will hold an MD/DO, have 1+ year UM experience in Medicare/Medicaid, demonstrate excellent communication, and possess US work authorization.