Utilization Management Physician Reviewer-FT

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Job Profile SummaryThe Utilization Management Physician Reviewer ensures timely and clinically sound coverage determinations for inpatient and outpatient services using evidence-based criteria, clinical judgment, and organizational policies. This role collaborates with internal and external care teams to recommend appropriate care and maintain compliance with CMS and payer guidelines. Responsibilities include reviewing service requests, documenting decisions, participating in quality improvement initiatives, and supporting care coordination efforts. Candidates must be licensed MDs or DOs with 3–5 years of clinical experience, including at least one year in utilization management for Medicare or Medicaid populations. Strong communication, managed care expertise, and attention to detail are essential for success.

Role Description: The Utilization Management Physician Reviewer-FT role is responsible for provisioning accurate and timely coverage determinations for inpatient and outpatient services by applying utilization management (UM) criteria, clinical judgment, and internal policies and procedures. Regardless of the final determination, the Physician Reviewer is responsible for ensuring medically appropriate care is recommended to the patient and their care team, which may require coordination with internal and external parties including, but not limited to requesting providers, external UM and case management staff, internal transitional care managers, employed primary care providers, and regional medical leaders. We strive for clinical excellence and ensuring our patients receive the right care, in the right setting, at the right time.

Core Responsibilities:

Review service requests and document the rationale for the decision in easy to understand language per organizational policies and procedures and industry standards; types of requests include but not limited to: Acute, Post-Acute, and Pre-service (Expedited, Standard, and Retrospective)

Use evidence-based criteria and clinical reasoning to make UM determinations in concert with an enrollee’s individual conditions and situation. The organization does not solely make authorization determinations based on criteria, but uses it as a tool to assist in decision making.

Work collaboratively with the Transitional Care and PCP care teams to drive efficient and effective care delivery to patients

Maintain knowledge of current CMS and MCG evidence-based guidelines to enable UM decisions

Maintain compliance with legal, regulatory and accreditation requirements and payor partner policies

Participate in initiatives to achieve and improve UM imperatives; for example, participate in committees or work-groups to help advance UM efforts and promote a culture of continuous quality improvement

Assist in formal responses to health plan regarding UM process or specific determinations on an as-needed basis

Adhere to regulatory and accreditation requirements of payor partners (e.g., site visits from regulatory & accreditation agencies, responses to inquiries from regulatory and accreditation agencies and payor partners, etc.)

Participate in rounding and patient panel management discussions as required

Fulfill on-call requirement, should the need arise

Other duties, as required and assigned

What are we looking for?
A current, clinical, in good standing, unrestricted license to practice medicine (NCQA Standard)

Graduate of an accredited medical school. M.D. or D.O. Degree is required. (NCQA Standard)
Experience: 3-5 years of clinical practice in a primary care setting with at least one year experience providing Utilization Management services to a Medicare and/or Medicaid line of business

Excellent verbal and written communication skills

Deep understanding of managed care, risk arrangements, capitation, peer review, performance profiling, outcome management, care coordination, and pharmacy management

Strong record of continuing education activities (relevant to practice area and needed to maintain licensure)

Demonstrated understanding of culturally responsive care

Proven organizational and detail-orientation skills

Anticipated Weekly Hours

40

Time Type

Full time

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