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Full - Time Utilization Management Physician Reviewer
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Full-time
- This full-time 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.
- 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, Post-Acute, and Pre-service (Expedited, Standard, and Retrospective)
- 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 evidence-based guidelines to enable UM decisions
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