Utilization Management Physician Reviewer

Working fully remote in a full-time capacity, the Utilization Management Physician Reviewer will be responsible for making accurate coverage determinations for inpatient and outpatient services by applying utilization management criteria and clinical judgment while ensuring appropriate care recommendations for patients. Key responsibilities Review service requests and document decision rationales in compliance with policies and industry standards Utilize evidence-based criteria and clinical reasoning to make informed UM determinations based on individual patient conditions Collaborate with care teams to enhance patient care delivery and participate in initiatives to improve utilization management practices Required qualifications At least one year of experience providing Utilization Management services to Medicare and/or Medicaid populations A current, unrestricted clinical license to practice medicine in the United States Graduate of an accredited medical school with an M.D. or D.O. degree 3-5 years of clinical practice experience in a primary care setting Strong understanding of managed care principles and relevant healthcare regulations