Remote Utilization Management Physician

CVS Health; United States; Remote; 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 Utilization Management Physician Reviewer to determine inpatient and outpatient coverage using UM criteria and clinical judgment. You will coordinate with care teams to ensure appropriate care, while aligning with CMS guidelines and organizational policies.

The role requires a US-licensed physician with 3–5 years of primary care experience, proficient communication, and a strong understanding of managed care and payor requirements.

Qualifications

• Active, unrestricted medical license in the United States (MD or DO).
• 3–5 years of clinical practice in a primary care setting.
• Experience providing utilization management services for Medicare/Medicaid.
• US work authorization in good standing.

Responsibilities

• Review service requests and document rationale per Oak Street Health policies and standards.
• Apply evidence-based UM criteria with clinical judgment for determinations.
• Collaborate with Transitional Care and PCP teams to improve care delivery.
• Maintain knowledge of CMS and MCG guidelines to support UM decisions.
• Ensure compliance with regulatory and accreditation requirements and payor policies.
• Participate in initiatives to advance UM efforts and quality improvement.

Skills

Communication skills

Clinical judgment

Utilization Management

Medicare/Medicaid knowledge

Regulatory compliance

Education

MD or DO degree

US medical license

Job description

Oak Street Health is seeking a Utilization Management Physician Reviewer to determine inpatient and outpatient coverage using UM criteria and clinical judgment. You will coordinate with care teams to ensure appropriate care, while aligning with CMS guidelines and organizational policies.

The role requires a US-licensed physician with 3–5 years of primary care experience, proficient communication, and a strong understanding of managed care and payor requirements.