Physician Reviewer-Utilization Management (Remote)
Physician Reviewer – Utilization Management (Remote)
Must have NC or FL license or IMLC
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.
Job Responsibilities: 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
Qualifications: 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 (IMLCC) 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
Working Hours: 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
Must have NC or FL license or IMLC
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.
Job Responsibilities: 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
Qualifications: 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 (IMLCC) 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
Working Hours: 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