Utilization Management Physician Reviewer

CVS Health; Chicago (IL); Remote; USD 90,000 - 120,000; Full time

Job summary

A leading health solutions company seeks a full-time Utilization Management Physician Reviewer to ensure accurate coverage determinations and promote efficient patient care. The role involves collaboration with care teams, compliance with regulations, and continuous quality improvement initiatives.

Qualifications

• At least one year of experience providing Utilization Management services for Medicare and/or Medicaid.
• 3-5 years of clinical practice in primary care.

Responsibilities

• Review service requests and document rationale for decisions.
• Collaborate with care teams to promote effective patient care delivery.
• Ensure compliance with legal and regulatory requirements.

Skills

Communication

Organizational Skills

Clinical Judgment

Education

M.D. or D.O. degree

Job description

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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 providing accurate and timely coverage determinations for inpatient and outpatient services by applying utilization management (UM) criteria, clinical judgment, and internal policies and procedures. The Physician Reviewer ensures medically appropriate care is recommended to the patient and their care team, which may involve coordination with internal and external parties, including requesting providers, external UM and case management staff, internal transitional care managers, employed primary care providers, and regional medical leaders. The goal is clinical excellence and ensuring patients receive the right care, in the right setting, at the right time.

Core Responsibilities

1. Review service requests and document the rationale for decisions clearly, following Oak Street Health policies and industry standards. Request types include but are not limited to: Acute, Post-Acute, and Pre-service (Expedited, Standard, and Retrospective).
2. Use evidence-based criteria and clinical reasoning to make UM determinations, considering individual patient conditions and situations. Oak Street Health uses criteria as a decision-making tool, not as the sole basis for authorization.
3. Collaborate with Oak Street Health Transitional Care and PCP care teams to promote efficient and effective patient care delivery.
4. Stay updated on CMS and MCG evidence-based guidelines to support UM decisions.
5. Ensure compliance with legal, regulatory, accreditation requirements, and payor policies.
6. Participate in initiatives to improve UM processes, including committees or workgroups, fostering a culture of continuous quality improvement.
7. Assist in formal responses to health plans regarding UM processes or specific determinations as needed.
8. Adhere to regulatory and accreditation requirements from payor partners, including site visits and inquiry responses.
9. Participate in rounding and patient panel management discussions as required.
10. Fulfill on-call duties if necessary.
11. Perform other duties as assigned.

Qualifications

• At least one year of experience providing Utilization Management services for Medicare and/or Medicaid.
• Excellent verbal and written communication skills.
• Unrestricted medical license to practice in the U.S. (NCQA Standard).
• Graduate of an accredited medical school with an M.D. or D.O. degree (NCQA Standard).
• 3-5 years of clinical practice in primary care.
• Deep understanding of managed care, risk arrangements, capitation, peer review, performance profiling, outcome management, care coordination, and pharmacy management.
• Active engagement in continuing education relevant to practice and licensure maintenance.
• Understanding of culturally responsive care.
• Strong organizational and detail-oriented skills.
• US work authorization.

What Being Oaky Looks 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 aims to rebuild healthcare by providing personalized primary care for Medicare-aged adults, focusing on keeping patients healthy and living fully. With over 150 locations and rapid growth, we attract team members who embody Oaky values and share our passion for our mission.

Oak Street Health is an equal opportunity employer, embracing diversity and encouraging all interested candidates to apply.