This physician reviews prior authorization, concurrent review, retrospective review, appeals, and grievances to assess medical necessity and appropriateness of services for managed care populations. The work is centered on utilization management for Medicare, Medicaid, Medicare Advantage, Special Needs Plans, and other risk-based lines of business, with close coordination across clinical staff and providers. In addition to case review, the role contributes to policy, clinical criteria, quality improvement, and population health efforts.
Key Responsibilities
- Conduct clinical review of prior authorization, concurrent review, retrospective review, appeals, and grievance requests.
- Assess medical necessity and appropriateness of services based on clinical criteria and utilization trends.
- Collaborate with utilization management nurses, clinical staff, and providers to support timely decision-making.
- Participate in fair hearing processes, interdisciplinary rounds, and case review meetings as needed.
- Ensure compliance with federal and state regulations, NCQA/URAC standards, and managed care organization policies.
- Serve as a liaison between the medical management department and providers.
- Contribute to policy development, clinical criteria, medical management strategies, and workflow updates.
- Support quality improvement initiatives and population health programs.
Required
- MD or DO degree.
- Active medical license in Ohio.
- Experience in health plan operations, medical management, or utilization management.
- Experience with managed care or government payor environments.
- Strong knowledge of healthcare regulations and compliance requirements.
Preferred
- Master’s degree in healthcare, business administration, or a related field.
- 10+ years of administrative leadership experience in health plan operations.
- CMO-level experience.
- Experience across multiple lines of business, such as Medicare, Medicaid, Healthcare Exchange, and Commercial.
- Experience leading teams, mentoring physicians, or managing complex operational change initiatives.
Benefits & Perks
- Competitive hourly pay range of $100.00 to $150.00.
- Friday schedule with flexibility to adjust to client needs as required.
- May require travel as needed by the client.
- Opportunity to work in a consulting role with multiple health plan and managed care engagements.
- Potential for client-facing strategic work and executive-level presentations.