Utilization Management Physician Reviewer
$174,070–$374,920 year
Remote · United States
Job Summary
Utilization Management Physician Reviewer at Oak Street Health (remote). Responsible for provisioning accurate and timely coverage determinations for inpatient and outpatient services by applying utilization management criteria, clinical judgment, and internal policies. Collaborates with Transitional Care, PCP care teams, external UM, and payor partners to drive efficient, appropriate care. Must review requests across Acute, Post-Acute, and Pre-service (Expedited, Standard, Retrospective) using CMS and MCG guidelines, maintain regulatory compliance, and participate in quality-improvement initiatives. Requires an MD or DO, an unrestricted U.S. medical license, 3-5 years of primary care experience, and US work authorization; demonstrated understanding of managed care, risk arrangements, care coordination, and payer policies. This is a full-time, remote role with a competitive pay range and comprehensive benefits; anticipated weekly hours are 40. Anticipated location is Remote (US).
Required Qualifications
- MD or DO license in the United States (clinical, unrestricted)
- Graduate of an accredited medical school
- 3-5 years of clinical practice in a primary care setting
- Current, clinical, unrestricted license to practice medicine in the United States (NCQA Standard)
- US work authorization
- Experience providing Utilization Management services for Medicare and/or Medicaid
- Ability to review service requests using CMS and evidence-based criteria
- Strong verbal and written communication skills
- Experience with regulatory/compliance requirements and payor partner policies
- Proficiency in care coordination and transitioning of care
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