Utilization Management Physician Reviewer, CVS Health

CVS Health

Location:
United States, Remote

Category:
Health and Beauty

Contract Type:
Employment contract

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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Utilization Management Physician Reviewer