Join to apply for the Medical Director, Utilization Management role at Oak Street Health, part of CVS Health .
Role Overview
The Medical Director, Utilization Management oversees the utilization management processes to ensure high-quality, cost-effective healthcare services. The role involves managing medical necessity reviews, coordinating care services, leading a UM team, and collaborating across departments to improve patient outcomes.
Core Responsibilities
Lead and manage the Utilization Management team, providing guidance, training, and support.
Support recruitment, hiring, and retaining skilled UM clinical staff.
Conduct regular performance evaluations, offering feedback and professional development.
Develop and implement UM policies and procedures in compliance with regulatory requirements.
Monitor and evaluate team performance, ensuring efficiency and effectiveness in all UM activities.
Utilization Review
Conduct and oversee clinical reviews of medical records to determine medical necessity.
Ensure timely and accurate prior authorizations, concurrent reviews, and retrospective reviews.
Collaborate with healthcare providers to facilitate appropriate utilization of 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 and gaps.
Implement evidence-based practices and clinical guidelines to enhance patient care outcomes.
Compliance and Regulation
Ensure compliance with all federal, state, and local regulations related to utilization management.
Stay current with changes in regulations and standards affecting UM practices.
Prepare and present reports to regulatory agencies, accrediting bodies, and internal stakeholders.
Collaboration and Communication
Work closely with Transitions, Case Management, and Care Teams to ensure coordinated care.
Communicate effectively with providers, patients, and stakeholders regarding UM decisions and policies.
Serve as a clinical resource and advisor to the UM team and other departments.
Other duties as assigned.
Qualifications
At least 2 years experience providing Utilization Management services to Medicare or Medicaid line of business.
Excellent verbal and written communication skills.
A current, clinical, unrestricted medical license in the United States (NCQA Standard).
Prior clinical leadership or supervision experience preferred.
Graduate of an accredited medical school; M.D. or D.O. 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.
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.
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 Statement
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 . The range represents the base hourly rate or base annual full-time salary for all positions in the job grade. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range. This position also includes an award target in the company’s equity award program.
Background Check Statement
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.