[Hiring] Utilization Management Physician Reviewer @CVS Health

Role Description

The Utilization Management Physician Reviewer ensures timely and clinically sound coverage determinations for inpatient and outpatient services using evidence-based criteria, clinical judgment, and organizational policies. This role collaborates with internal and external care teams to recommend appropriate care and maintain compliance with CMS and payer guidelines. Responsibilities include reviewing service requests, documenting decisions, participating in quality improvement initiatives, and supporting care coordination efforts.

The Utilization Management Physician Reviewer-FT 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
• 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:

• Weekend Coverage is Required
• Review service requests and document the rationale for the decision in easy to understand language per organizational 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.
• Work collaboratively with the Transitional Care and PCP care teams to drive efficient and effective care delivery to patients.
• Maintain knowledge of current CMS and MCG evidence-based guidelines to enable UM decisions.
• Maintain compliance with legal, regulatory and accreditation requirements and payor partner policies.
• Participate in initiatives to achieve and improve UM imperatives; for example, participate in committees or work-groups to help advance UM efforts and promote a culture of continuous quality improvement.
• Assist in formal responses to health plan regarding UM process or specific determinations on an as-needed basis.
• Adhere 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 required.
• Fulfill on-call requirement, should the need arise.
• Other duties, as required and assigned.

Qualifications

• A current, clinical, in good standing, unrestricted license to practice medicine (NCQA Standard).
• Graduate of an accredited medical school. M.D. or D.O. Degree is required. (NCQA Standard).
• Experience: 3-5 years of clinical practice in a primary care setting with at least one year experience providing Utilization Management services to a Medicare and/or Medicaid line of business.
• Excellent verbal and written communication skills.
• 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 (relevant to practice area and needed to maintain licensure).
• Demonstrated understanding of culturally responsive care.
• Proven organizational and detail-orientation skills.

Requirements

• Anticipated Weekly Hours: 40
• Time Type: Full time

Benefits

• Affordable medical plan options.
• 401(k) plan (including matching company contributions).
• Employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

Company Description

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll 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.