Physician Reviewer-Utilization Management

Physician Reviewer - Utilization Management (Remote) 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 (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 Schedule & Call Hours: 8:00 AM - 5:00 PM (local time zone) Call Rotation: 1 weekend every 16 weeks Physician Reviewer - Utilization Management (Remote) 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 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 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 We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA). As a job position within our Allied division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: providing direct patient care, accessing medical and confidential records, accessing and administering prescription medication or other drugs, working within a clinical setting, handling sharp instruments, conducting medical procedures, and working within departments that care for vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.

Created: 2026-03-04