Utilization Management Physician Reviewer

Hispanic Alliance for Career Enhancement; Culver City (CA); Remote; USD 174,000 - 375,000; Full time

Job summary

An established industry player is seeking a dedicated Utilization Management Physician Reviewer to ensure patients receive appropriate care. This full-time remote role involves making coverage determinations, collaborating with care teams, and ensuring compliance with regulatory standards. The ideal candidate will have experience in Medicare/Medicaid, strong communication skills, and a commitment to quality care. Join a mission-driven organization focused on personalized primary care for Medicare older adults, offering comprehensive benefits and a supportive work environment.

Benefits

Medical Plans

401(k)

Stock Purchase Plans

Wellness Programs

Paid Time Off

Flexible Schedules

Qualifications

• At least one year of UM experience with Medicare and/or Medicaid.
• Current, unrestricted medical license in the US.

Responsibilities

• Provide accurate and timely coverage determinations for inpatient and outpatient services.
• Collaborate with care teams to promote efficient and effective care delivery.

Skills

Utilization Management (UM)

Clinical Judgment

Communication Skills

Managed Care Knowledge

Organizational Skills

Education

M.D. or D.O. degree

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 more connected, more convenient, and more 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 involves providing accurate and timely coverage determinations for inpatient and outpatient services by applying utilization management (UM) criteria, clinical judgment, and internal policies. The Physician Reviewer ensures medically appropriate care is recommended, coordinating with providers, UM and case management staff, transitional care managers, primary care providers, and medical leaders. 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 decisions clearly, including types such as Acute, Post-Acute, and Pre-service requests (Expedited, Standard, and Retrospective).
• Use evidence-based criteria and clinical reasoning to make UM determinations, considering individual patient conditions.
• Collaborate with care teams to promote efficient and effective care delivery.
• Stay informed of CMS and MCG guidelines to support UM decisions.
• Ensure compliance with legal, regulatory, and accreditation standards, as well as payor policies.
• Participate in initiatives to improve UM processes and promote quality improvement.
• Assist with formal responses to health plans regarding UM determinations.
• Comply with regulatory and accreditation requirements, including site visits and inquiries.
• Participate in rounding and patient panel discussions as needed.
• Fulfill on-call duties if required.
• Perform other duties as assigned.

Qualifications:

• At least one year of UM experience with Medicare and/or Medicaid.
• Excellent verbal and written communication skills.
• Current, unrestricted medical license in the US.
• Graduation from an accredited medical school with an M.D. or D.O. degree.
• 3-5 years of clinical primary care experience.
• Deep understanding of managed care, risk arrangements, capitation, peer review, and care coordination.
• Commitment to continuing education and culturally responsive care.
• Strong organizational and detail-oriented skills.
• US work authorization.
• Embodies Oaky values such as positivity, ownership, and determination.

Why Oak Street Health?

Our mission is to rebuild healthcare with personalized primary care for Medicare older adults, focusing on quality over volume. With over 150 locations and rapid growth, we attract passionate team members who embody Oaky values.

We are an equal opportunity employer, embracing diversity and encouraging all to apply. Learn more at our diversity and inclusion initiatives.

Additional Details:

• Anticipated weekly hours: 40
• Time type: Full-time
• Pay range: $174,070 - $374,920, depending on experience and other factors

We offer comprehensive benefits including medical plans, 401(k), stock purchase plans, wellness programs, paid time off, flexible schedules, and more. For details, visit our benefits page.

Application deadline: 04/22/2026. Qualified applicants will be considered regardless of arrest or conviction records in accordance with applicable laws.