Utilization Management Physician Reviewer

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.

Job Profile Summary
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.

Candidates must be licensed MDs or DOs with 3–5 years of clinical experience, including at least one year in utilization management for Medicare or Medicaid populations. Strong communication, managed care expertise, and attention to detail are essential for success.

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 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 decisions in clear, easy‑to‑understand language per organizational policies and procedures and industry standards. Types of requests include 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 use criteria to make authorization determinations, but uses them 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, serve on 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).
• 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…