Role Description
The Medical Director, Utilization Management is responsible for overseeing the utilization management (UM) processes to ensure the delivery of high-quality, cost-effective healthcare services. This role involves managing the review of medical necessity, appropriateness of care, and the coordination of healthcare services. The Medical Director will lead and manage a team of UM professionals, providing guidance, support, and professional development opportunities to optimize team performance. Additionally, the Medical Director will collaborate with various departments, healthcare providers, and external stakeholders to enhance healthcare delivery and improve patient outcomes.
Core Responsibilities
Leadership and Management
Lead and manage the Utilization Management team, providing guidance, training, and support.
Support recruiting, hiring, and retaining skilled UM clinical staff, fostering a collaborative and high-performance work environment.
Conduct regular performance evaluations, offering feedback, coaching, and professional development opportunities.
Develop and implement UM policies and procedures in compliance with regulatory requirements and industry standards in conjunction with other UM Leadership.
Monitor and evaluate the performance of the UM team, ensuring efficiency and effectiveness in all UM activities.
Utilization Review
Conduct and oversee clinical reviews of medical records to determine the medical necessity and appropriateness of healthcare services.
Ensure timely and accurate review of prior authorizations, concurrent reviews, and retrospective reviews.
Collaborate with healthcare providers to facilitate appropriate utilization of healthcare resources.
Quality Assurance and Improvement
Develop and implement quality assurance programs to monitor and improve UM processes.
Analyze UM data and metrics to identify trends, gaps, and areas for improvement.
Implement evidence-based practices and clinical guidelines to enhance patient care and outcomes.
Compliance and Regulation
Ensure compliance with all federal, state, and local regulations related to utilization management.
Stay current with changes in healthcare regulations and standards affecting UM practices.
Prepare and present reports to regulatory agencies, accrediting bodies, and internal stakeholders as required.
Collaboration and Communication
Work closely with other departments, including Transitions, Case Management, and Care Teams, to ensure coordinated and integrated care.
Communicate effectively with healthcare providers, patients, and other stakeholders regarding UM decisions and policies.
Serve as a clinical resource and advisor to the UM team and other departments.
Other duties as assigned.
What are we looking for?
An ideal candidate will satisfy the following:
At least 2 years 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)
Prior clinical leadership or supervision experience is preferred.
Graduate of an accredited medical school. M.D. or D.O. Degree is required. (NCQA Standard)
3-5 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 detail-orientation skills
Ability to collaborate effectively with a staff, providers, and a diverse group of leaders.
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. We're 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 Benefits
Mission-focused career impacting change and measurably improving health outcomes for Medicare patients
Paid vacation, sick time, and investment/retirement 401K match options
Health insurance, vision, and dental benefits
Opportunities for leadership development and continuing education stipends
New centers and flexible work environments
Opportunities for high levels of responsibility and rapid advancement
Equal Opportunity Employer
Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.
Pay Range
The typical pay range for this role is: $174,070.00 - $374,920.00
Benefits to Employees
Great benefits for great people 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.
More Information
For more information, visit https://jobs.cvshealth.com/us/en/benefits
Application Window
We anticipate the application window for this opening will close on: 10/16/2026