Utilization Management Physician Reviewer

CVS Health•Chicago, IL

1d•Remote

About The Position

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. Regardless of the final determination, the Physician Reviewer is responsible for ensuring medically appropriate care is recommended to the patient and their care team, which may require coordination with internal and external parties including, but not limited to: requesting providers, external UM and case management staff, internal transitional care managers, employed primary care providers, and regional medical leaders. We strive for clinical excellence and ensuring our patients receive the right care, in the right setting, at the right time.

Requirements

At least one year experience providing Utilization Management services to a Medicare and/or Medicaid line of business
Excellent verbal and written communication skills
A current, clinical, unrestricted license to practice medicine in the United States. (NCQA Standard)
Graduate of an accredited medical school. M.D. or D.O. Degree is required. (NCQA Standard)
3-5 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 practice area and needed to maintain licensure)
Demonstrated understanding of culturally responsive care
Proven organizational and detail-orientation skills
US work authorization

Nice To Haves

Someone who embodies being Oaky

Responsibilities

Review service requests and document the rationale for the decision in easy to understand language per Oak Street Health policies and procedures and industry standards; types of requests include but not limited to: Acute, Post-Acute, and Pre-service (Expedited, Standard, and Retrospective)
Use evidence-based criteria and clinical reasoning to make UM determinations in concert with an enrolleeâ€™s individual conditions and situation. OSH does not solely make authorization determinations based on criteria, but uses it as a tool to assist in decision making.
Work collaboratively with the Oak Street Health Transitional Care and PCP care teams to drive efficient and effective care delivery to patients
Maintain knowledge of current CMS and MCG evidence-based guidelines to enable UM decisions
Maintain compliance with legal, regulatory and accreditation requirements and payor partner policies
Participate in initiatives to achieve and improve UM imperatives; for example, participate in committees or work-groups to help advance UM efforts at Oak Street and promote a culture of continuous quality improvement
Assist in formal responses to health plan regarding UM process or specific determinations on an as-needed basis
Adhere to regulatory and accreditation requirements of payor partners (e.g., site visits from regulatory & accreditation agencies, responses to inquiries from regulatory and accreditation agencies and payor partners, etc.)
Participate in rounding and patient panel management discussions as required
Fulfill on-call requirement, should the need arise
Other duties, as required and assigned