Utilization Management Physician Reviewer

Job not on LinkedIn

🔥 4 hours ago

🌽 Illinois – Remote

🌽 Illinois – Remote

💵 $230k / year

⏰ Full Time

🟢 Junior

👻 Ghost score 0%

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CVS Health Careers

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛒 Retail

📦 Logistics

Healthcare • Retail • Logistics

CVS Health Careers is the recruitment and employer branding arm of CVS Health, showcasing job opportunities across the company's broad operations—pharmacy retail stores, pharmacy services, health care clinics, distribution warehouses, corporate functions and transportation. The careers site emphasizes purpose-driven work focused on improving access, affordability and quality of health care, and highlights a large workforce (300,000+ employees), inclusive culture, benefits, and hiring resources for applicants.

📋 Description

• Provision accurate and timely coverage determinations for inpatient and outpatient services • Apply utilization management criteria, clinical judgment, and internal policies and procedures • Ensure medically appropriate care is recommended to patients and care teams • Coordinate with requesting providers, external UM and case management staff, internal transitional care managers, employed primary care providers, and regional medical leaders • Review service requests and document decision rationale in easy-to-understand language • Use evidence-based criteria and clinical reasoning to make UM determinations based on individual conditions and situations • Collaborate with Transitional Care and PCP care teams to drive efficient and effective care delivery • Maintain knowledge of current CMS and MCG evidence-based guidelines • Maintain compliance with legal, regulatory, accreditation, and payor partner requirements • Participate in UM committees, work-groups, and continuous quality improvement initiatives • Assist with formal responses to health plans regarding UM processes or determinations • Participate in rounding and patient panel management discussions • Fulfill on-call requirements as needed • Perform other assigned duties

🎯 Requirements

• At least one year of experience providing Utilization Management services to a Medicare and/or Medicaid line of business • Excellent verbal and written communication skills • Current, clinical, unrestricted license to practice medicine in the United States • Graduate of an accredited medical school • M.D. or D.O. degree required • 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 • Embodies being Oaky

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being, based on eligibility

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