Utilization Management Physician Reviewer

divh2Full-Time Utilization Management Physician Reviewer/h2pWere building a world of health around every individual shaping a more connected, convenient and compassionate health experience. At CVS Health, youll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger helping to simplify health care one person, one family and one community at a time./ppCompany: Oak Street Health/ppLocation: Remote/ Treehouse/ppRole Description:/ppThis 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./ppCore Responsibilities:/pulliReview 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)/liliUse evidence-based criteria and clinical reasoning to make UM determinations in concert with an enrollees 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./liliWork collaboratively with the Oak Street Health Transitional Care and PCP care teams to drive efficient and effective care delivery to patients/liliMaintain knowledge of current CMS and MCG evidence-based guidelines to enable UM decisions/liliMaintain compliance with legal, regulatory and accreditation requirements and payor partner policies/liliParticipate 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 improvement/liliAssist in formal responses to health plan regarding UM process or specific determinations on an as-needed basis/liliAdhere 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.)/liliParticipate in rounding and patient panel management discussions as required/liliFulfill on-call requirement, should the need arise/liliOther duties, as required and assigned/li/ulpWhat are we looking for?/pulliAt least one year experience providing Utilization Management services to a Medicare and/or Medicaid line of business/liliExcellent verbal and written communication skills/liliA current, clinical, unrestricted license to practice medicine in the United States. (NCQA Standard)/liliGraduate of an accredited medical school. M.D. or D.O. Degree is required. (NCQA Standard)/lili3-5 years of clinical practice in a primary care setting/liliDeep understanding of managed care, risk arrangements, capitation, peer review, performance profiling, outcome management, care coordination, and pharmacy management/liliStrong record of continuing education activities (relevant to practice area and needed to maintain licensure)/liliDemonstrated understanding of culturally responsive care/liliProven organizational and detail-orientation skills/liliUS work authorization/liliSomeone who embodies being Oaky/li/ulpWhat does being Oaky look like?/pulliRadiating positive energy/liliAssuming good intentions/liliCreating an unmatched patient experience/liliDriving clinical excellence/liliTaking ownership and delivering results/liliBeing relentlessly determined/li/ulpWhy Oak Street Health?/ppOak 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 patients communities, and focused on the quality of care over volume of services. Were 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./ppOak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply./ppAnticipated Weekly Hours/pp40/ppTime Type/ppFull time/ppPay Range/ppThe typical pay range for this role is:/pp$174,070.00 - $374,920.00/ppThis pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors./ppOur people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong./ppGreat benefits for great people/ppWe take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full?time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well?being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility./ppAdditional details about available benefits are provided during the application process and on Benefits Moments./p/div