Utilization Management Physician Reviewer

CVS Pharmacy; Chicago (IL); Remote; USD 174,000 - 375,000; Full time

Job summary

An established industry player is seeking a dedicated Utilization Management Physician Reviewer to join their team. This full-time role involves making timely coverage determinations for inpatient and outpatient services while ensuring patients receive appropriate care. The ideal candidate will leverage their clinical expertise and communication skills to collaborate with various care teams and uphold compliance with regulatory standards. With a focus on quality over quantity, this organization is committed to transforming healthcare for older adults, offering a supportive environment for professional growth and development. If you're passionate about making a difference in healthcare, this opportunity is perfect for you.

Benefits

Affordable medical plan options

401(k) plan with company matching

Employee stock purchase plan

Wellness screenings

Tobacco cessation programs

Weight management programs

Confidential counseling

Financial coaching

Tuition assistance

Flexible work schedules

Qualifications

• 1+ year experience in Utilization Management for Medicare/Medicaid.
• Current clinical license to practice medicine in the US required.

Responsibilities

• Provision of accurate coverage determinations for services.
• Collaborate with care teams to ensure effective patient care.

Skills

Utilization Management

Clinical Judgment

Communication Skills

Organizational Skills

Culturally Responsive Care

Education

M.D. or D.O. Degree

Graduate of an accredited medical school

Job description

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Company: Oak Street Health

Title: Full-Time Utilization Management Physician Reviewer

Location: Remote/Treehouse

Role Description:

This full-time role is responsible for provisioning accurate and timely coverage determinations for inpatient and outpatient services by applying utilization management (UM) criteria, clinical judgment, and internal policies and procedures. Regardless of the final determination, the Physician Reviewer is responsible for ensuring medically appropriate care is recommended to the patient and their care team, which may require coordination with internal and external parties including, but not limited to: requesting providers, external UM and case management staff, internal transitional care managers, employed primary care providers, and regional medical leaders. We strive for clinical excellence and ensuring our patients receive the right care, in the right setting, at the right time.

Core Responsibilities:

• Review service requests and document the rationale for the decision in easy to understand language per Oak Street Health policies and procedures and industry standards; types of requests include but are not limited to: Acute, Post-Acute, and Pre-service (Expedited, Standard, and Retrospective).
• Use evidence-based criteria and clinical reasoning to make UM determinations in concert with an enrollee’s individual conditions and situation. OSH does not solely make authorization determinations based on criteria, but uses it as a tool to assist in decision making.
• Work collaboratively with the Oak Street Health Transitional Care and PCP care teams to drive efficient and effective care delivery to patients.
• Maintain knowledge of current CMS and MCG evidence-based guidelines to enable UM decisions.
• Maintain compliance with legal, regulatory and accreditation requirements and payor partner policies.
• Participate in initiatives to achieve and improve UM imperatives; for example, participate in committees or work-groups to help advance UM efforts at Oak Street and promote a culture of continuous quality improvement.
• Assist in formal responses to health plan regarding UM process or specific determinations on an as-needed basis.
• Adhere to regulatory and accreditation requirements of payor partners (e.g., site visits from regulatory & accreditation agencies, responses to inquiries from regulatory and accreditation agencies and payor partners, etc.).
• Participate in rounding and patient panel management discussions as required.
• Fulfill on-call requirement, should the need arise.
• Other duties, as required and assigned.

What are we looking for?

• 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. (NCQA Standard)
• Graduate of an accredited medical school. M.D. or D.O. Degree is required. (NCQA Standard)
• 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 needed to maintain licensure).
• Demonstrated understanding of culturally responsive care.
• Proven organizational and detail-orientation skills.
• US work authorization.
• Someone who embodies being Oaky.

What does being Oaky look like?

• Radiating positive energy.
• Assuming good intentions.
• Creating an unmatched patient experience.
• Driving clinical excellence.
• Taking ownership and delivering results.
• Being relentlessly determined.

Why Oak Street Health?

Oak Street Health is on a mission to Rebuild healthcare as it should be, providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patient’s communities, and focused on the quality of care over volume of services. We’re an organization on the move! With over 150 locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oaky values and passion for our mission.

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.

Learn more at www.oakstreethealth.com/diversity-equity-and-inclusion-at-oak-street-health.

Anticipated Weekly Hours: 40

Time Type: Full time

Pay Range: The typical pay range for this role is: $174,070.00 - $374,920.00. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people:

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits.

We anticipate the application window for this opening will close on: 04/22/2026.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.