Utilization Management Physician Reviewer

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

Job summary

A leading health solutions company is seeking a full-time Utilization Management Physician Reviewer. This role involves making coverage determinations for services, ensuring clinical excellence, and collaborating with care teams to provide appropriate patient care. Ideal candidates will have experience in managed care and possess strong communication and organizational skills.

Benefits

Medical Plans

401(k)

Employee Stock Purchase

Wellness Programs

Paid Time Off

Flexible Schedules

Family Leave

Tuition Assistance

Qualifications

• At least one year of experience providing UM 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 teams to promote efficient care delivery.
• Ensure compliance with legal and regulatory requirements.

Skills

Communication

Organizational Skills

Clinical Judgment

Education

M.D. or D.O. degree

Job description

Join to apply for the Utilization Management Physician Reviewer role at Oak Street Health.

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 more connected, convenient, and compassionate. 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. The Physician Reviewer ensures medically appropriate care is recommended to the patient and their care team, coordinating with internal and external parties as needed. Our goal is clinical excellence and ensuring patients receive the right care, in the right setting, at the right time.

Core Responsibilities

• Review service requests and document the rationale for decisions clearly, following Oak Street Health policies and industry standards. Requests include Acute, Post-Acute, and Pre-service (Expedited, Standard, and Retrospective).
• Use evidence-based criteria and clinical reasoning to make UM determinations, considering individual patient conditions. UM decisions are supported by criteria but also rely on clinical judgment.
• Collaborate with Oak Street Health teams to promote efficient and effective care delivery.
• Maintain knowledge of current CMS and MCG evidence-based guidelines to inform UM decisions.
• Ensure compliance with legal, regulatory, accreditation requirements, and payor policies.
• Participate in initiatives to improve UM processes and promote quality improvement culture.
• Assist in formal responses to health plans regarding UM processes or determinations as needed.
• Adhere to regulatory and accreditation standards of payor partners.
• Participate in rounding and patient panel management discussions as required.
• Fulfill on-call duties if needed.
• Perform other duties as assigned.

Qualifications

• At least one year of experience providing UM services for Medicare and/or Medicaid.
• Excellent verbal and written communication skills.
• Current, unrestricted medical license 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, 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.
• U.S. work authorization.

Additional Information

We value embodying being Oaky: radiating positive energy, assuming good intentions, creating an unmatched patient experience, driving clinical excellence, taking ownership, and being relentlessly determined.

Why Oak Street Health? We aim to rebuild healthcare with personalized primary care for older adults on Medicare, focusing on quality over volume. With over 150 locations and a growth trajectory, we seek team members who embody our values and passion.

Our benefits include medical plans, 401(k), employee stock purchase, wellness programs, paid time off, flexible schedules, family leave, tuition assistance, and more. For details, visit our benefits page.

Application deadline: 05/13/2026. We consider applicants with arrest or conviction records in accordance with laws.

Job Details

• Seniority level: Mid-Senior level
• Employment type: Full-time
• Job function: Health Care Provider
• Industries: Hospitals and Health Care