Utilization Management Physician Reviewer

CVS Health • Chicago, IL

1d • Remote

About The Position

Oak Street Health, a CVS Health company, is seeking a fully remote Utilization Management Physician Reviewer. This full-time role provides accurate and timely coverage determinations for inpatient and outpatient services by applying utilization management criteria, clinical judgment, and internal policies and procedures. The reviewer also ensures that medically appropriate care is recommended to patients and their care teams, coordinating with internal and external parties as needed. The position supports clinical excellence and appropriate care in the right setting and at the right time.

The role works collaboratively with Oak Street Health transitional care and primary care teams, maintains knowledge of current CMS and MCG guidelines, and supports compliance with regulatory, accreditation, and payor requirements. The schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. CST, with on-call duties if needed. The position is fully remote and full-time.

Requirements

• At least one year of experience providing utilization management services for a Medicare and/or Medicaid line of business.
• Excellent verbal and written communication skills.
• Current, clinical, unrestricted license to practice medicine in the United States.
• M.D. or D.O. degree from an accredited medical school.
• Three to five 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 the practice area and required to maintain licensure.
• Demonstrated understanding of culturally responsive care.
• Proven organizational and detail-orientation skills.
• U.S. work authorization.
• Embody Oak Street Health’s Oaky values: radiating positive energy, assuming good intentions, creating an unmatched patient experience, driving clinical excellence, taking ownership and delivering results, and being relentlessly determined.

Responsibilities

• Review acute, post-acute, and pre-service requests, including expedited, standard, and retrospective requests, and document determination rationales in clear language consistent with company policies and industry standards.
• Apply evidence-based criteria and clinical reasoning in light of each enrollee’s individual conditions and situation; criteria are used as a decision-support tool rather than the sole basis for authorization determinations.
• Collaborate with Oak Street Health transitional care and primary care teams to support efficient and effective care delivery.
• Maintain knowledge of current CMS and MCG evidence-based guidelines for utilization management decisions.
• Maintain compliance with legal, regulatory, accreditation, and payor partner requirements.
• Participate in initiatives, committees, or work groups to advance utilization management and continuous quality improvement.
• Assist with formal responses to health plans concerning utilization management processes or specific determinations as needed.
• Support regulatory and accreditation activities, including site visits and responses to inquiries from agencies and payor partners.
• Participate in rounding and patient panel management discussions as required.
• Fulfill on-call requirements if needed.
• Perform other duties as required and assigned.

Benefits

• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources to support physical, emotional, and financial well-being, based on eligibility

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Ph.D. or professional degree