Utilization Review Physician

Overview We are seeking a high-performing Physician Reviewer to join our Group Health division. The role is responsible for delivering timely, defensible utilization review determinations across a high-volume, fast-paced environment. Reviews span multiple case types, including preauthorization, appeals, DRG clinical validation, benefit review, and experimental/investigational determinations. Key Responsibilities Perform utilization review for: Preauthorization requests Appeals (first and second level) Independent external reviews DRG validation and clinical review Benefit and coverage determinations Experimental/Investigational (E/I) review Apply evidence-based criteria and guidelines, including: InterQual MCG CMS guidelines (including 2-Midnight Rule)

LCD/NCD

Client-specific policies Produce clear, concise, and defensible clinical rationales Maintain high accuracy and consistency across determinations Meet or exceed turnaround time (TAT) expectations, including urgent cases Participate in peer-to-peer discussions as needed Collaborate with QA and operational teams to ensure quality and compliance Reviews may be conducted within internal systems or client-specific platforms, depending on assignment and client requirements Performance Metrics High daily review volume with strong accuracy Consistent adherence to client-specific requirementsAbility to manage short-TAT and urgent cases efficiently Clear, audit-ready documentation Required Qualifications MD or DO, board-certified in Internal Medicine, Family Medicine, or similar Active, unrestricted medical license Prior utilization review experience, preferably in a health plan or IRO environment Familiarity with InterQual, MCG, and CMS guidelines Strong clinical judgment and documentation skills Ability to work independently in a high-throughput environment Technical Skills Proficiency with standard business tools (e.g., Google Workspace, Microsoft Office) Comfortable working across multiple systems, including internal platforms and client-specific portals Strong navigation and documentation skills within web-based applications Ability to manage multiple systems/screens simultaneously in a high-throughput environment Familiarity with Mac operating systems Work Environment Remote work from home Full-time, Monday–Friday Availability for occasional weekends and holiday coverage for urgent reviews Benefits Medical, dental, and vision coverage for you and your family Voluntary life insurance options for you, your spouse, and your children Other voluntary benefits: hospital indemnity, critical illness, accident indemnity, pet insurance plans Employees receive basic life insurance, short-term disability, and long-term disability coverage at no cost Generous paid time off policy 401(k) plan with company match Apple equipment and media stipend for remote workspace #J-18808-Ljbffr Dane Street, LLC