Utilization Management Physician Reviewer

CVS Health•Chicago, IL

1d•Remote

About The Position

The Utilization Management Physician Reviewer provides accurate and timely coverage determinations for inpatient and outpatient services by applying utilization management criteria, clinical judgment, and internal policies and procedures. Regardless of the determination, the reviewer helps ensure medically appropriate care is recommended to patients and their care teams, coordinating as needed with requesting providers, external utilization management and case management staff, internal transitional care managers, employed primary care providers, and regional medical leaders. The role supports clinical excellence by helping patients receive the right care in the right setting at the right time. It is fully remote, full-time, and scheduled Monday through Friday, 8 a.m. to 5 p.m. The role may also include an on-call requirement if needed.

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, unrestricted clinical 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 relevant to the practice area and licensure maintenance.
Demonstrated understanding of culturally responsive care.
Proven organizational and attention-to-detail skills.
U.S. work authorization.
Alignment with Oak Street Health’s “Oaky” values.

Responsibilities

Review service requests—including acute, post-acute, and pre-service requests (expedited, standard, and retrospective)—and document decision rationales in clear language consistent with Oak Street Health policies, procedures, and industry standards.
Use evidence-based criteria and clinical reasoning, considering each enrollee’s individual conditions and circumstances, to make utilization management 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, and work groups to advance utilization management and continuous quality improvement.
Assist with formal responses to health plans regarding 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.