Utilization Management Physician Reviewer

Toney Healthcare provides expert guidance and solutions to enhance health plans' clinical operations. Our team of over 250 professionals, which includes renowned physician advisors, senior nurse executives, and healthcare specialists, delivers tailored strategies to address organizational needs and improve outcomes for diverse populations. With a deep understanding of the challenges and opportunities faced by risk-bearing entities, we focus on medical management, quality, compliance, accreditation, and beyond. Headquartered in Tampa, FL, we serve clients nationwide across all lines of business, offering trusted expertise and best practices. Role Description This is a remote contract role for a Utilization Management Physician Reviewer. Responsibilities include conducting clinical reviews to evaluate medical necessity, appropriateness and efficiency of healthcare services. The role involves reviewing medical records, applying clinical guidelines, collaborating with healthcare providers and providing expert recommendations for care management. The position requires strong clinical knowledge and a commitment to ensuring quality standards are met. Qualifications MD or DO with current, unrestricted license to practice medicine. Minimum 5 years of clinical experience in behavioral health settings. At least 2 years of experience in utilization management, care review, or health plan operations (preferred). Familiarity with utilization review criteria, regulatory standards, and managed care principles. Strong decision-making, analytical, and interpersonal communication skills. Proficiency in EMR and UM platforms (e.g., Jiva or similar systems). #J-18808-Ljbffr