Utilization Management Physician Reviewer

Full-Time Utilization Management Physician ReviewerThis full-time role is responsible for provisioning accurate and timely coverage determinations for inpatient and outpatient services by applying utilization management (UM) criteria, clinical judgment, and internal policies and procedures. Regardless of the final determination, the Physician Reviewer is responsible for ensuring medically appropriate care is recommended to the patient and their care team, which may require coordination with internal and external parties including, but not limited to: requesting providers, external UM and case management staff, internal transitional care managers, employed primary care providers, and regional medical leaders. We strive for clinical excellence and ensuring our patients receive the right care, in the right setting, at the right time.Core Responsibilities:Review service requests and document the rationale for the decision in easy to understand language per Oak Street Health policies and procedures and industry standards; types of requests include but not limited to: Acute, Post-Acute, and Pre-service (Expedited, Standard, and Retrospective)Use evidence-based criteria and clinical reasoning to make UM determinations in concert with an enrollee's individual conditions and situation. OSH does not solely make authorization determinations based on criteria, but uses it as a tool to assist in decision making.Work collaboratively with the Oak Street Health Transitional Care and PCP care teams to drive efficient and effective care delivery to patientsMaintain knowledge of current CMS and MCG evidence-based guidelines to enable UM decisionsMaintain compliance with legal, regulatory and accreditation requirements and payor partner policiesParticipate in initiatives to achieve and improve UM imperatives; for example, participate in committees or work-groups to help advance UM efforts at Oak Street and promote a culture of continuous quality improvementAssist in formal responses to health plan regarding UM process or specific determinations on an as-needed basisAdhere to regulatory and accreditation requirements of payor partners (e.g., site visits from regulatory & accreditation agencies, responses to inquiries from regulatory and accreditation agencies and payor partners, etc.)Participate in rounding and patient panel management discussions as requiredFulfill on-call requirement, should the need ariseOther duties, as required and assignedWhat are we looking for?At least one year experience providing Utilization Management services to a Medicare and/or Medicaid line of businessExcellent verbal and written communication skillsA current, clinical, unrestricted license to practice medicine in the United States. (NCQA Standard)Graduate of an accredited medical school. M.D. or D.O. Degree is required. (NCQA Standard)3-5 years of clinical practice in a primary care settingDeep understanding of managed care, risk arrangements, capitation, peer review, performance profiling, outcome management, care coordination, and pharmacy managementStrong record of continuing education activities (relevant to practice area and needed to maintain licensure)Demonstrated understanding of culturally responsive careProven organizational and detail-orientation skillsUS work authorizationSomeone who embodies being OakyWhat does being Oaky look like?Radiating positive energyAssuming good intentionsCreating an unmatched patient experienceDriving clinical excellenceTaking ownership and delivering resultsBeing relentlessly determinedWhy Oak Street Health?Oak Street Health is on a mission to Rebuild healthcare as it should be, providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patient's communities, and focused on the quality of care over volume of services. We're an organization on the move! With over 150 locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oaky values and passion for our mission.Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.