Utilization Management Physician Reviewer

Job Overview The Physician Reviewer serves as a clinical subject matter expert in the Utilization Management (UM) department. This role is responsible for conducting clinical reviews of medical necessity, appropriateness of care, and service requests based on evidence-based guidelines, medical policy, and regulatory requirements. The Physician Reviewer collaborates with UM nurses, medical directors, and other healthcare professionals to ensure appropriate, timely, and cost-effective care for members. Key Responsibilities:

• Conduct physician-level reviews of prior authorization, concurrent review, and retrospective review cases across multiple lines of business (e.g., commercial, Medicaid, Medicare).
• Apply nationally recognized clinical criteria (e.g., MCG, InterQual), internal medical policies, and applicable regulations (CMS, NCQA, URAC) to review determinations.
• Render clinical decisions in a timely manner consistent with regulatory timeframes and health plan policies.
• Collaborate with medical directors, case managers, and care teams to support optimal care pathways.
• Participate in audits, appeals, and grievance processes as needed.
• Maintain current knowledge of clinical best practices, industry trends, and regulatory changes.
• Participate in peer-to-peer discussions with attending physicians to communicate UM decisions and promote evidence-based care.
• Analyze clinical data and documentation to support accurate determinations and appeals.
• Contribute to the development and refinement of clinical policies and UM protocols specific to specialized care.
• Provide guidance on clinical appropriateness, benefit coverage, and policy interpretation.
• Provide education and clinical support to internal teams and external providers regarding best practices and clinical pathways.
• Ensure compliance with regulatory, accreditation, and legal requirements in all UM activities.
• Ensure adherence to all HIPAA, confidentiality, and privacy standards.
• Participate in quality improvement initiatives and clinical case rounds.

Qualifications:

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree required.
• Active and unrestricted medical license.
• Minimum of 5 years of clinical practice experience in the respective specialty.
• At least 3 years of experience in utilization management within a health plan.
• Familiarity with evidence-based guidelines and UM tools (e.g., InterQual, MCG).
• Strong communication and documentation skills.
• Proficiency with electronic medical records and clinical review platforms.
• Experience with Medicare/Medicaid and commercial insurance regulations is preferred.

Preferred Skills:

• Experience with Medicare and/or Medicaid managed care plans.
• Knowledge of medical necessity appeal processes and peer review protocols.
• Knowledge of CMS, NCQA, and/or URAC standards.
• Previous peer review or medical director experience.
• Comfortable working in a remote, collaborative environment.

Pay: From $175.00 per hour Experience:

• Utilization Management Review: 3 years (Required)
• Medicare and/or Medicaid: 2 years (Preferred)

License/Certification:

• Board-certified M.D. or D.O. medical license? (Required)

Work Location: Remote Apply tot his job Apply To this Job