Utilization Management Physician Reviewer Job at CVS Health (Remote)

Physician Peer Reviewer

A vital role of the CMO Administration team, the Medical Peer Reviewer plays a c...

Location

United States

Salary:

122907.00 - 188020.00 USD / Year

Healthfirst

Expiration Date

Until further notice

Requirements

Licensed M.D. or D.O. or D.M.D. or D.D.S.
Board Certified in a specialty recognized by the American Board of Medical Specialties
New York State Board Certified in Internal Medicine or Family Practice
Previous, relevant experience in utilization management and clinical practice
Knowledge of Medicare, Medicaid, and MLTC plans
Time management, critical thinking, communication, and problem-solving skills
Knowledge of UM//QM case philosophies and reporting requirements to state and federal agencies
Knowledge of member satisfaction//incident management and regulations
Knowledge of quality improvement methodologies
Ensures compliance to internal Healthfirst and external regulations

Job Responsibility

Assess//review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations
Render determinations in the format and within timeframes to follow Regulatory and Operational policies
Maintain productivity standards
Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases//caseload from multiple lines of businesses
Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members//internal medical departments as needed
Complete mandatory Company compliance training and training in new systems and software
Enter each day’s hours worked in Workday, on the same day
Perform other duties as assigned

What we offer

medical, dental and vision coverage
incentive and recognition programs
life insurance
401k contributions
Paid Time Off (PTO)
Holiday pay

Parttime

Supervisor, Utilization Management

The Utilization Management Care Coordinator Supervisor helps meet the goal of en...

Location

United States , Chicago

Salary:

43888.00 - 93574.00 USD / Year

CVS Health

Expiration Date

January 31, 2026

Requirements

Bachelor's degree in healthcare administration, nursing, or a related field
Minimum of 3 years of experience in utilization management, healthcare operations, or a similar role, with demonstrated leadership experience
Strong understanding of utilization management principles, healthcare regulations, and industry standards
Desire to lead and motivate a team
Excellent analytical, problem-solving, and decision-making skills
A flexible, positive attitude even within a rapidly changing environment
Ability to build and maintain positive relationships across all organizational levels
Strong communication and interpersonal skills, with the ability to collaborate effectively across multidisciplinary teams
A high level of integrity and alignment with our mission to provide high quality patient care
Proficiency in utilization management software systems and Microsoft Office applications

Job Responsibility

Directly supervises a team of 3-10 Utilization Management Care Coordinators
Provides daily direction and communication to ensure efficient and effective utilization of healthcare resources
Ensures all coordinators have appropriate training, tools, and resources
Monitors productivity reports, MD queues, escalations inbox, Slack, and operational trackers
Responds to emails, questions, errors, and concerns from care teams and external partners
Provides support to UM physician reviewers
Creates and maintains a positive work environment
Delivers performance reviews, feedback, and coaching
Contributes to workflow development and process improvement
Evaluates processes and procedures

What we offer

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
No-cost wellness screenings
Tobacco cessation and weight management programs
Confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources

Fulltime

Supervisor, Utilization Management

At CVS Health, we’re building a world of health around every consumer and surrou...

Location

United States , Illinois

Salary:

43888.00 - 93574.00 USD / Year

CVS Health

Expiration Date

January 31, 2026

Requirements

Bachelor's degree in healthcare administration, nursing, or a related field
Minimum of 3 years of experience in utilization management, healthcare operations, or a similar role, with demonstrated leadership experience
Strong understanding of utilization management principles, healthcare regulations, and industry standards
Desire to lead and motivate a team
Excellent analytical, problem-solving, and decision-making skills
A flexible, positive attitude even within a rapidly changing environment
Ability to build and maintain positive relationships across all organizational levels
Strong communication and interpersonal skills, with the ability to collaborate effectively across multidisciplinary teams
A high level of integrity and alignment with our mission to provide high quality patient care
Proficiency in utilization management software systems and Microsoft Office applications

Job Responsibility

Directly supervises a team of 3-10 Utilization Management Care Coordinators, providing daily direction and communication to ensure efficient and effective utilization of healthcare resources while maintaining compliance with regulatory standards and organizational policies
Ensures all coordinators have the appropriate training, tools, and resources to perform their roles and identifies appropriate solutions when gaps arise
Meets productivity and quality expectations through the daily direction and delegation of work to coordinators
Monitors productivity reports, MD queues, escalations inbox, Slack, and operational trackers on a daily basis. Adjusts staff assignments to ensure work is appropriately prioritized
Responds to emails, questions, errors, and concerns posed by care teams and external partners in a manner that is timely, professional, and generates trust
Provides support to UM physician reviewers as needed for questions or escalated issues
Creates and maintains a positive work environment by routinely recognizing, engaging, and advocating for their team of coordinators
Delivers performance reviews, feedback, and coaching as needed to their team
Actively contributes to workflow development and process improvement in support of departmental standards and strategic directives
Continually evaluates processes and procedures. Responsible for suggesting methods to improve daily operations, efficiency, and service to both internal and external partners

What we offer

Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility

Fulltime

Medical Director of Revenue Integrity

The Physician Advisor is a key member of the healthcare organization’s leadershi...

Location

United States , Cheyenne

Salary:

Not provided

Cheyenne Regional Medical Center

Expiration Date

Until further notice

Requirements

Hold and maintain or able to obtain an unrestricted medical license in the state of Wyoming
Possess or acquires a solid foundation, knowledge, and/or experience in the areas of utilization management, quality improvement, and patient safety
Familiarity with InterQual and MCG is preferred
Strong understanding of Medicare Two Midnight Rules
Member of the American College of Physician Advisors (ACPA)
Board Certification by the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) or ACPA is required within 6 months of hire
Ability to build rapport with medical staff and hospital leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes
Prefer Internal Medicine specialist with a background in Hospital Medicine
Maintain active medical practice in their specialty (Can accommodate clinical time up to 0.15 FTE in the specialty (depending on availability))
Demonstrates behavior that supports the organization’s mission

Job Responsibility

Provide functional leadership for the revenue integrity team Including CDI, Coding and Utilization Review
Responsible for oversight revenue integrity optimization
Lead value-based care initiatives for the organization
Chairs the Utilization Management Team
Review medical records of patients identified by case managers or as requested by the healthcare team including physicians to perform quality and utilization oversight
Perform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews
Conduct Peer to Peer discussion with Payor Medical Directors when requested
Provide regular feedback to physicians and all other stake holders regarding level of care, length of stay, and potential quality issues
Provide necessary clinical education to UR Case Managers regarding clinical criteria and appropriate use of screening tools
Educates individual hospital staff physicians about ICD-10 and DRG coding guidelines (e.g., co-morbid conditions, outpatient vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records

What we offer

403(b) with 4% employer match
ANCC Magnet Hospital
$10,000 relocation bonus
$3,500 in CMEs
216 hours of PTO
Robust Benefits Package

Physician Peer Reviewer

A vital role of the CMO Administration team, the Medical Peer Reviewer plays a c...

Location

United States

Salary:

122907.00 - 188020.00 USD / Year

Healthfirst

Expiration Date

Until further notice

Requirements

Licensed M.D. or D.O. or D.M.D. or D.D.S.
Board Certified in a specialty recognized by the American Board of Medical Specialties

Job Responsibility

Assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations
Render determinations in the format and within timeframes to follow Regulatory and Operational policies
Maintain productivity standards
Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases/caseload from multiple lines of businesses
Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as needed
Complete mandatory Company compliance training and training in new systems and software
Enter each day’s hours worked in Workday, on the same day
Perform other duties as assigned

What we offer

Medical, dental and vision coverage
Incentive and recognition programs
Life insurance
401k contributions
Paid Time Off (PTO)
Holiday pay

Parttime

Utilization Management Nurse Specialist RN II

The Utilization Management Nurse Specialist RN II facilitates, coordinates, and ...

Location

United States , Los Angeles

Salary:

88854.00 - 142166.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Associate's Degree in Nursing
At least 5 years of varied RN clinical experience in an acute hospital setting
At least 2 years of Utilization Management/Case Management experience in a hospital or HMO setting
Registered Nurse (RN) - Active, current and unrestricted California License
Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint
Provision of excellent customer service required
Excellent time management and priority-setting skills
Maintains strict member confidentiality and complies with all HIPAA requirements
Strong verbal and written communication skills

Job Responsibility

Facilitates, coordinates, and approves medically necessary referrals that meet established criteria
Assures timely and accurate determination and notification of referrals and reconsiderations
Generates approval, modification and denial communications
Actively monitors for admissions in any inpatient setting
Performs telephonic and/or onsite admission and concurrent review
Collaborates with onsite staff, physicians, providers, member/family to develop and implement a successful discharge plan
Works with the UM Manager and Physician Advisor on case reviews
Monitors and oversees the collection and transfer of data (medical records) and referral requests by Providers
Acts as a department resource for medical service requests /referral management and processes
Receives incoming calls from providers, professionally handles complex calls

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Physician Advisor

The Physician Advisor (PA) serves as a clinical resource to the medical staff an...

Location

United States , Miami

Salary:

Not provided

Baptist Health

Expiration Date

Until further notice

Requirements

Doctor of Medicine / DO
ABQAURP Physician Advisor Sub-Specialty Certification
Medical Doctor
Osteopathic Physician
Maintains active Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) license
If license is not a state of Florida license, active State of Florida License must be obtained within one year of hire/job entry
Certification as Physician Advisor by a national physician advisor organization or American Board of Quality Assurance and Utilization Review Physicians [ABQAURP] certification or similar must be obtained within one year of hire
A minimum of 3 years work experience as practicing physician, with experience performing case reviews, and experience using MCG and/or Interqual criteria
Knowledge on application of CMS 2 Midnight Rule, and Condition of Participation, and inpatient billing requirements
Ability to analyze, organize and prioritize work accurately while meeting multiple deadlines

Job Responsibility

Serves as a clinical resource to the medical staff and CM/SW by providing identification, facilitation and resolution of utilization issues
Addresses the following issues: Federal and state compliance, documentation supporting coding/medical necessity/clinical validation, appropriate level of care, length of stay, hospital utilization and quality issues
In collaboration with admitting physician, healthcare team, and case management, proactively manages cases at the point of entry and through the hospital stay, to ensure the patient is placed in the proper level of care classification based on medical necessity, severity of illness and risk of mortality
Ensures compliance with CMS for appropriate billing
Conducts post-discharge reviews related to payer audits
Promotes understanding and cooperation between the medical staff through communication, collaboration and education
Facilitate improvements in clinical practice to achieve better performance, improved cost, reduced length of stay, fewer readmissions, and superior patient care

Fulltime

Physician Advisor

The Physician Advisor (PA) serves as a clinical resource to the medical staff an...

Location

United States , Boynton Beach

Salary:

Not provided

Baptist Health

Expiration Date

Until further notice

Requirements

Degrees: Doctor of Medicine / DO
Licenses & Certifications: ABQAURP Physician Advisor Sub-Specialty Certification
Additional Qualifications: Certification as Physician Advisor by a national physician advisor organization or American Board of Quality Assurance and Utilization Review Physicians [ABQAURP] certification or similar must be obtained within one year of hire
A minimum of 3 years work experience as practicing physician, with experience performing case reviews, and experience using MCG and/or Interqual criteria
Knowledge on application of CMS 2 Midnight Rule, and Condition of Participation, and inpatient billing requirements
Ability to analyze, organize and prioritize work accurately while meeting multiple deadlines
Ability to communicate effectively in both oral and written form
Ability to handle difficult and stressful situations with critical thinking and professional composure
Ability to understand and follow instructions
Ability to exercise sound and independent judgment

Job Responsibility

Serves as a clinical resource to the medical staff and CM/SW by providing identification, facilitation and resolution of utilization issues
Addresses the following issues: Federal and state compliance, documentation supporting coding/medical necessity/clinical validation, appropriate level of care, length of stay, hospital utilization and quality issues
In collaboration with admitting physician, healthcare team, and case management, proactively manages cases at the point of entry and through the hospital stay, to ensure the patient is placed in the proper level of care classification based on medical necessity, severity of illness and risk of mortality
Ensures compliance with CMS for appropriate billing
Conducts post-discharge reviews related to payer audits
Promotes understanding and cooperation between the medical staff through communication, collaboration and education
Facilitate improvements in clinical practice to achieve better performance, improved cost, reduced length of stay, fewer readmissions, and superior patient care

What we offer

Relocation assistance available

Fulltime

Utilization Management Physician Reviewer

CVS Health

Location:
United States , Remote

Category:
Health and Beauty

Contract Type:
Employment contract

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
August 27, 2025

Expiration:
August 21, 2026

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