Utilization Management Physician Reviewer
$174,070–$374,920 year
RemoteUnited States
Job Summary
Review service requests and document rationales for Acute, Post-Acute, and Pre-service determinations using evidence-based criteria and clinical judgment. Collaborate with Transitional Care and PCP teams to ensure medically appropriate care is recommended, coordinating with providers and regional medical leaders as needed. Maintain knowledge of current CMS and MCG guidelines while adhering to legal, regulatory, and accreditation requirements for payor partners. Participate in quality improvement initiatives, formal responses to health plans, and patient panel management discussions. Fulfill on-call requirements as assigned. This full-time role requires 40 weekly hours and supports Oak Street Health's mission to rebuild healthcare for older adults through personalized primary care.
Required Qualifications
- 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
- 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
Desired Qualifications
- Someone who embodies being Oaky
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