Utilization Management Physician Reviewer

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Company:Oak Street Health

Title:FullTime Utilization Management Physician Reviewer

Location:Remote/ Treehouse

Role Description:

This fulltime 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 PostAcute and Preservice (Expedited Standard and Retrospective)

• Use evidencebased 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.

• Work collaboratively with the Oak Street Health Transitional Care and PCP care teams to drive efficient and effective care delivery to patients

• Maintain knowledge of current CMS and MCG evidencebased 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 workgroups to help advance UM efforts at Oak Street and promote a culture of continuous quality improvement

• Assist in formal responses to health plan regarding UM process or specific determinations on an asneeded 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 oncall requirement should the need arise

• Other duties as required and assigned

What are we looking for

• At least one year experience providing Utilization Management services to a Medicare and/or Medicaid line of business

• Excellent verbal and written communication skills

• A 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)

• 35 years of clinical practice in a primary care setting

• 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 detailorientation skills

• US work authorization

• Someone who embodies being Oaky

What does being Oaky look like

• Radiating positive energy

• Assuming good intentions

• Creating an unmatched patient experience

• Driving clinical excellence

• Taking ownership and delivering results

• Being relentlessly determined

Why 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 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.

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

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