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Utilization Management Physician Reviewer at CVS Health - ApplyBlast

Utilization Management Physician Reviewer

CVS Health

5 months ago

3.2 on Glassdoor

Remote

Full Time

Senior

0 applicants

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About this role

Oak Street Health seeks a Utilization Management Physician Reviewer to provide accurate and timely coverage determinations for inpatient and outpatient services. This role requires applying clinical judgment and UM criteria to ensure medically appropriate care while coordinating with various internal and external teams. The position focuses on clinical excellence and guiding patients and care teams regarding the right care in the right setting.

Responsibilities

Review service requests and document rationale for coverage determinations
Apply evidence-based criteria and clinical reasoning for UM decisions
Coordinate with transitional care managers and regional medical leaders
Maintain knowledge of CMS and MCG guidelines for UM decisions
Participate in committees to advance utilization management efforts

Skills

Qualifications

MD or DO DegreeUnrestricted Medical License3-5 Years Primary Care ExperienceMedicare/Medicaid UM ExperienceOne Year Utilization Management Experience

About CVS Health

cvshealth.com

Headquarters

Woonsocket, Rhode Island, United States

Company Size

10001+ employees

Founded

1963

View Profile

CVS Health is America's leading health solutions company, providing integrated services across retail pharmacy (CVS Pharmacy), pharmacy benefits management (CVS Caremark), and health insurance (Aetna). The company offers pharmacy services, health plans, clinical care (including MinuteClinic), and health-and-wellness programs for consumers, employers, and government payers. By combining a large national retail footprint with claims processing, care management, and clinical services, CVS Health aims to coordinate care, lower costs, and improve health outcomes. Businesses and consumers use its solutions for medication management, plan administration, and in-person and virtual care.