HealthVine - Utilization Management Physician Reviewer – Pediatric Medicaid ACO

The Utilization Management (UM) Physician Reviewer at Cincinnati Children’s ensures that pediatric Medicaid members receive medically necessary, evidence-based, and cost-effective care. Working within an Accountable Care Organization (ACO) model, this role supports care quality, utilization efficiency, and compliance with Medicaid regulations. The position involves clinical review, interdisciplinary collaboration, and strategic input into population health initiatives.

-This position is remote with a schedule of Monday through Friday 8:00am-5:00pm EST with minimal weekend and holiday on call requirements. Telecommuting on a full-time basis may be permitted in the following states: Alabama, Arizona, Arkansas, Florida, Georgia, Idaho, Iowa, Kansas, Louisiana, Michigan, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, and Wyoming.

Key Responsibilities:

• Conduct prospective, concurrent, and retrospective reviews of medical services for pediatric Medicaid members.

• Apply clinical guidelines (e.g., MCG) and Medicaid-specific criteria to assess medical necessity.

• Participate in peer-to-peer discussions with treating providers to clarify clinical information and support appropriate care decisions.

• Collaborate with RN Specialists, Senior RN Specialist and Clinical Director to support integrated care planning.

• Provide clinical input on complex cases involving social determinants of health, chronic conditions, or developmental disabilities.

• Support transitions of care, especially from inpatient to outpatient settings, to reduce readmissions.

• Ensure adherence to federal and state Medicaid regulations, NCQA standards, and ACO performance metrics.

• Participate in - Participates in interrater reliability audit process, quality improvement initiatives, and utilization trend analysis.

• Contribute to the development of clinical policies, pathways, and educational materials for providers.

• Advise on utilization trends and opportunities for cost containment and care optimization.

• Support the implementation of value-based care initiatives and pediatric population health strategies.

• Serve as a subject matter expert in pediatric care for internal and external stakeholders.

Qualifications:

• MD or DO degree from an accredited medical school.

• Board Certification in Pediatrics (ABP) required; subspecialty certification (e.g., Pediatric Emergency Medicine, Pediatric Hospital Medicine) preferred.

• Active, unrestricted medical license in the state of Ohio.

• Certified in Utilization Management (e.g., CHCQM-PHYADV from ABQAURP) or willingness to obtain within 12 months of hire.

• Basic Life Support (BLS) certification (if clinically active).

• Familiarity with HIPAA, NCQA, and CMS guidelines.

• Minimum 3-5 years of clinical experience, pediatric experience preferred

• 1–2 years in utilization management, managed care, or ACO settings preferred.

• Experience with Medicaid populations and pediatric health disparities is highly desirable.

• Proficiency with Epic , MCG and UM platforms.

 

Primary Location

Remote

 

Schedule

Full time

 

Shift

Day (United States of America)

 

Department

HealthVine

 

Employee Status

Regular

 

FTE

1

 

Weekly Hours

40

Market Leading Benefits Including*:  

• Medical coverage starting day one of employment. View employee benefits here. 

• Competitive retirement plans  

• Tuition reimbursement for continuing education  

• Expansive employee discount programs through our many community partners  

• Shift Differential, Weekend Differential, and Weekend Option Pay Programs for qualified positions 

• Support through Employee Resource Groups such as African American Professionals Advisory Council, Asian Cultural and Professional Group, EQUAL - LGBTQA Resource Group, Juntos - Hispanic/Latin Resource Group, Veterans and Military Family Advocacy Network, and Young Professionals (YP) Resource Group  

• Physical and mental health wellness programs  

• Relocation assistance available for qualified positions 

*Benefits may vary based on FTE Status and Position Type 

 

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