Clinicians in this role perform medical necessity reviews for prior authorization, concurrent review, retrospective review, and related appeals for managed care populations, including Medicare Advantage, Medicaid, Special Needs Plans, and complex care members. The work focuses on utilization management decisions, provider communication, and support for quality and population health initiatives. In addition to review work, the role includes strategic consulting, policy development, and cross-functional collaboration with clinical and operational teams.
Key Responsibilities
- Conduct clinical review of prior authorization, concurrent review, retrospective review, appeals, and grievance requests.
- Determine medical necessity and appropriateness of services using clinical criteria and utilization trends.
- Collaborate with utilization management nurses and clinical staff to support timely decision-making.
- Serve as a liaison between medical management and providers on clinical criteria and utilization issues.
- Participate in interdisciplinary rounds and case review meetings as needed.
- Support compliance with federal and state regulations, NCQA/URAC standards, and MCO policies.
- Contribute to policy, clinical criteria, workflow, and medical management strategy development.
- Support quality improvement initiatives and population health programs as needed.
Required
- MD or DO degree.
- Active Texas medical license.
- Board eligibility or training in Pediatrics, Family Medicine, or Internal Medicine.
- 10+ years of administrative leadership experience in health plan operations with progressive responsibility.
- 7+ years of experience in a government payor environment with medical management expertise.
- Experience leading teams, projects, and complex operational change in a health plan or consulting setting.
Preferred
- Master’s degree in Healthcare Administration, Business Administration, or a related field.
- CMO-level experience.
- Experience across multiple lines of business, such as Medicare, Medicaid, Commercial, or Exchange plans.
- Experience mentoring other physicians in a health plan setting.
- Experience with complex regulatory frameworks such as CMS, NCQA, URAC, HIPAA, and state insurance requirements.
Benefits & Perks
- Full-time or part-time schedule available.
- Monday through Friday schedule with ability to adjust to client needs.
- Travel may be required as needed by the client.
- Remote work across Eastern or Central time zones.
- Salary range of $100.00 to $150.00 per hour.