Physician Reviewer for Utilization Management

2 weeks ago

Chicago, Illinois, United States Oak Street Health Full time


Company: Oak Street Health

Title: Full-Time Utilization Management Physician Reviewer

Location: Remote/ Treehouse

Role Overview:

This full-time position is dedicated to delivering precise and prompt coverage decisions for both inpatient and outpatient services by utilizing utilization management (UM) criteria, clinical expertise, and established internal policies. The Physician Reviewer plays a crucial role in ensuring that medically appropriate care is recommended to patients and their healthcare teams, which may involve collaboration with various internal and external stakeholders, including requesting providers, external UM and case management personnel, internal transitional care managers, primary care providers, and regional medical leaders. Our commitment is to clinical excellence, ensuring our patients receive the right care, in the right environment, at the right time.

Key Responsibilities:
  • Evaluate service requests and articulate the rationale for decisions in clear, comprehensible language in accordance with Oak Street Health policies and industry standards; requests may include Acute, Post-Acute, and Pre-service (Expedited, Standard, and Retrospective)
  • Employ evidence-based criteria and clinical judgment to make UM determinations tailored to an enrollee's unique conditions and circumstances. OSH utilizes criteria as a supportive tool in decision-making rather than the sole basis for authorization determinations.
  • Collaborate effectively with the Oak Street Health Transitional Care and PCP care teams to facilitate efficient and effective patient care delivery
  • Stay informed on current CMS and MCG evidence-based guidelines to support UM decision-making
  • Ensure compliance with legal, regulatory, and accreditation standards, as well as payor partner policies
  • Engage in initiatives aimed at enhancing UM objectives; for instance, participate in committees or workgroups to advance UM efforts at Oak Street and foster a culture of continuous quality improvement
  • Assist in formal communications to health plans regarding UM processes or specific determinations as needed
  • Comply with 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 required
  • Fulfill on-call responsibilities, should the need arise
  • Perform other duties as assigned
Qualifications:
  • A minimum of one year of experience in providing Utilization Management services to Medicare and/or Medicaid populations
  • Exceptional verbal and written communication abilities
  • A current, unrestricted clinical license to practice medicine in the United States. (NCQA Standard)
  • Graduation from an accredited medical school. An M.D. or D.O. degree is required. (NCQA Standard)
  • 3-5 years of clinical experience in a primary care environment
  • Comprehensive understanding of managed care, risk arrangements, capitation, peer review, performance profiling, outcome management, care coordination, and pharmacy management
  • Strong record of continuing education activities relevant to the practice area and necessary for maintaining licensure
  • Demonstrated understanding of culturally responsive care
  • Proven organizational skills and attention to detail
  • Authorization to work in the United States
  • An individual who embodies the values of Oak Street Health
What does embodying Oak Street Health values look like?
  • Exuding positive energy
  • Assuming good intentions from others
  • Creating an exceptional patient experience
  • Driving clinical excellence
  • Taking ownership and delivering results
  • Demonstrating relentless determination
Why choose Oak Street Health?

Oak Street Health is committed to transforming healthcare by providing personalized primary care for older adults on Medicare, with the aim of keeping patients healthy and engaged in life. Our innovative care model is rooted in the communities we serve, prioritizing quality of care over the volume of services. We are a growing organization with over 150 locations, attracting and nurturing team members who share our values and passion for our mission.

Oak Street Health is an equal opportunity employer. We celebrate diversity and encourage all interested candidates to apply.

Learn more at

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