This physician role focuses on utilization management and medical necessity review for Medicaid members, with decisions covering prior authorization, concurrent review, acute and post-acute care, and pharmacy-related reviews. The work is primarily remote and includes peer-to-peer discussions with treating providers, first-level appeal determinations, and collaboration with multidisciplinary clinical and operational teams. It is a physician leadership position with rotating on-call coverage, including weekends and holidays.
Key Responsibilities
- Conduct medical necessity reviews and utilization management determinations for Medicaid members.
- Provide prior authorization and precertification reviews for covered services.
- Review concurrent inpatient and outpatient care, including acute and post-acute services.
- Participate in peer-to-peer consultations with treating providers.
- Complete pharmacy reviews and first-level appeal determinations.
- Collaborate with medical management, clinical, and operational teams to support timely decisions.
- Participate in a rotating on-call schedule with weekend and holiday coverage.
Required
- Active, unrestricted medical license.
- Ability to be licensed in Florida and Kentucky.
- MD or DO degree.
- Current, active board certification in an ABMS- or AOA-recognized specialty.
- At least 5 years of post-residency clinical practice and direct patient care experience.
Preferred
- Active, unrestricted Louisiana medical license.
- Board certification in Family Medicine, Emergency Medicine, or Internal Medicine-Pediatrics.
- Prior utilization management experience with a health plan, managed care organization, independent review organization, or as a physician advisor.
- Medicaid and managed care experience.
- Experience with medical necessity review, prior authorization, concurrent review, appeals, and peer-to-peer consultation.
- Experience using electronic health records and other clinical documentation systems.
Benefits & Perks
- Work-from-home arrangement.
- Full-time position.
- Medical, dental, and vision coverage.
- Paid time off.
- Retirement savings options.
- Wellness programs.
- Eligibility for bonus, commission, or short-term incentive program.
- Equity award program eligibility.