Remote Physician Reviewer-Utilization Management-249027
Physician Reviewer – Utilization Management (Remote)-Full Time
- *Overview**
We are seeking a Board-Certified Physician to support utilization management activities by reviewing clinical documentation and determining the medical appropriateness of inpatient, outpatient, and pharmacy services. This role plays a critical part in ensuring evidence-based, high-quality, and cost-effective care decisions. The ideal candidate brings strong clinical judgment, experience within managed care, and the ability to apply nationally recognized medical guidelines in a fast-paced, collaborative environment.
Key Responsibilities
- Review and assess medical necessity for inpatient, outpatient, and pharmacy services
- Apply evidence-based guidelines and medical policy to utilization review determinations
- Provide peer-to-peer consultations when required
- Collaborate with care management and clinical teams to support appropriate care delivery
- Ensure compliance with regulatory, accreditation, and internal quality standards
- Accurately document decisions within established systems and turnaround times
Required Qualifications
- MD or DO with active Board Certification
- Active medical license in
- *FL or NC**
, and/or participation in the
- *Interstate Medical Licensure Compact (IMLC)**
or eligibility to apply
- Minimum
- *6 years of clinical practice experience
- At least
- *1 year of utilization review experience
within a managed care or health plan environment
Preferred Qualifications
- Licensure in multiple states
- Board Certification in
- *Cardiology, Radiation Oncology, or Neurology**
• Experience with care management within the health insurance industry
- Willingness and ability to obtain additional state licenses as needed
Schedule & Call
- Hours:
8:00 AM – 5:00 PM (local time zone)
- Call Rotation:
1 weekend every 16 weeks Apply tot his job Apply To this Job