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Utilization Management Physician Reviewer

https://www.cvshealth.com/ Logo

CVS Health

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Location:
United States , Remote

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Category:
Health and Beauty

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Contract Type:
Employment contract

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Salary:

174070.00 - 374920.00 USD / Year
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Job Description:

Full-time role responsible for provisioning accurate and timely coverage determinations for inpatient and outpatient services by applying utilization management criteria, clinical judgment, and internal policies and procedures. Ensuring medically appropriate care is recommended to patients and their care teams.

Job Responsibility:

  • Review service requests and document the rationale for the decision
  • Use evidence-based criteria and clinical reasoning to make UM determinations
  • Work collaboratively with the Oak Street Health Transitional Care and PCP care teams
  • Maintain knowledge of current CMS and MCG evidence-based guidelines
  • Maintain compliance with legal, regulatory and accreditation requirements
  • Participate in initiatives to achieve and improve UM imperatives
  • Assist in formal responses to health plan regarding UM process
  • Adhere to regulatory and accreditation requirements of payor partners
  • Participate in rounding and patient panel management discussions
  • Fulfill on-call requirement

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
  • Graduate of an accredited medical school with M.D. or D.O. Degree
  • 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
  • Demonstrated understanding of culturally responsive care
  • Proven organizational and detail-orientation skills
  • US work authorization

Nice to have:

  • Someone who embodies being Oaky
  • Radiating positive energy
  • Assuming good intentions
  • Creating an unmatched patient experience
  • Driving clinical excellence
  • Taking ownership and delivering results
  • Being relentlessly determined
What we offer:
  • Affordable medical plan options
  • 401(k) plan with matching company contributions
  • Employee stock purchase plan
  • Wellness screenings
  • Tobacco cessation and weight management programs
  • Confidential counseling and financial coaching
  • Paid time off
  • Flexible work schedules
  • Family leave
  • Dependent care resources
  • Colleague assistance programs
  • Tuition assistance
  • Retiree medical access

Additional Information:

Job Posted:
August 27, 2025

Expiration:
August 21, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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