Medical Director,Utilization Management

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.

Company: Oak Street Health 

Title: Medical Director, Utilization Management

Location: Treehouse

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, UM 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 patient’s 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

 

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

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  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 listed above.  This position also includes an award target in the company’s equity award program. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits 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.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 10/16/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.