Utilization Management Physician Reviewer-FT

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Role Description: 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, 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 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. The organization does not solely make authorization determinations based on criteria, but uses it as a tool to assist in decision making.

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

What are we looking for?
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

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

This 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.  
 

Our 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.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an 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.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.