Remote Utilization Management Physician

Job Posting: Medical Director – Utilization Management (Remote) Position: Medical Director – Utilization Management Location: Remote (Anywhere in the US) Employment Type: 1099 Contract Hours: Full-Time, 40 hours/week Meaningful Payer-Side Impac t: Work directly within a major national health plan, influencing decisions that impact member care quality, compliance, and operational strateg y.Stable Full-Time Hour s: Enjoy a fully remote, 40-hour work week that offers the professional autonomy and structural balance many physicians look for when transitioning to payer-side role s.Seamless Integratio n: Step into an established, well-oiled UM operation where your existing expertise is highly valued, featuring a streamlined 2-day training block to get you up to spee d.Key Responsibiliti esAs a Medical Director, you will provide clinical expertise and guidance on complex cases, ensuring high-quality, compliant review processe s.Conduct utilization management reviews for medical necessity, appropriateness of care, and efficiency across commercial inpatient and outpatient service s.Review escalated cases utilizing established medical policy criteria and guidelines (e.g., MCG, InterQual ).Conduct peer-to-peer discussions with attending physicians and providers as neede d.Support appeals, grievances, and prior authorization review workflow s.Maintain a high-volume, efficient workflow, comfortably managing a production target of approximately 55+ cases per 8-hour da y.Ensure strict compliance with NCQA, CMS, URAC, and all applicable state and federal regulatory standard s.Collaborate cross-functionally with operational and clinical leadership team s.Position Requiremen ts### ABSOLUTE MUST-HAVE REQUIREMEN T: Candidate s mu st possess direct health plan/payer-side utilization management experience. Hospital-only case management or health system review experience will not be considered for this rol e.Required Qualificatio nsDegre e: MD or DO from an accredited institutio n.Certificatio n: Active Board Certificatio n.Licensur e: Active, unrestricted medical license . Must hold a current license in at least one of the following states: New York (NY), Pennsylvania (PA), or West Virginia (WV ).Experienc e: Multiple years of dedicated payer-side/health insurance utilization management experience working specifically as a Medical Director or Physician Reviewe r.System s: Experience working within managed care workflows, utilizing production queues, EMR platforms (Epic preferred), and strict turnaround time (TAT) metric s.Work Styl e: Ability to work completely independently and productively in a fast-paced, remote production environmen t.Preferred Experien ceExperience supportin g Medicare Advanta ge and/o r Commerci al lines of busines s.Multi-state medical licensur e.Prior experience heavily focused on prior authorizations, appeals, and grievance s.