Physician Reviewer

Job Title: Medical Director – Utilization Management (Contract to Hire) Location: Fully Remote, but need license for the state (PA, NY or WV) Schedule: 40 hours/week Core: 9am–5pm EST (flexible after training) Overview Seeking experienced Medical Directors with payer-side utilization management experience to support high-volume medical necessity reviews. This is a contract-to-hire opportunity working within a structured, compliance-driven environment. What You’ll Do Review escalated cases against medical policy criteria to determine medical necessity Complete initial determinations, appeals, and grievance reviews Conduct peer-to-peer calls when required Participate in multidisciplinary team discussions (case reviews, rounds) Support guideline development and clinical projects Expected throughput: 55+ cases per day Systems: Predictal, Beacon Required Qualifications MD or DO Board Certified (ABMS or AOA) 5+ years direct patient care experience Active, unrestricted license in PA, NY, or WV Strong clinical judgment, documentation, and communication skills Managed care / utilization management knowledge required Must have payer-side utilization management experience Health plan / insurance experience required Hospital-only UM experience will not be considered Preferred Experience with MCG or InterQual Prior health plan medical management experience MBA, MHA, or MPH