This physician role focuses on utilization management reviews for Commercial, Medicare Advantage, FEP, and appeals cases, with regular peer-to-peer discussions about medical necessity and coverage determinations. The work is remote and contract-based, with clinical decisions guided by evidence and supported by collaboration with providers and internal teams. The position also contributes to medical policy development, quality improvement, and broader operational initiatives.
Key Responsibilities
- Perform utilization management reviews across multiple lines of business.
- Conduct peer-to-peer discussions with treating providers regarding coverage determinations and medical necessity.
- Review prior authorizations, appeals, and medical policy cases.
- Provide clinical guidance to internal business partners and cross-functional teams.
- Analyze clinical data to support quality improvement and operational initiatives.
- Partner with providers and healthcare stakeholders to improve clinical outcomes and member experience.
- Contribute to medical policy development and strategic healthcare initiatives.
- Participate in an on-call rotation with minimal weekend coverage.
Required
- MD or DO from an accredited medical school.
- Completion of an accredited residency program.
- Active North Carolina medical license.
- Board certification in an ABMS- or AOA-recognized specialty.
- At least 7 years of relevant clinical experience.
- Experience in utilization management within a health plan, managed care organization, or payer environment.
Preferred
- Experience supporting both government and commercial health plans.
- Prior Medical Director or physician advisor experience.
- Experience with medical policy and evidence-based coverage determinations.
Benefits & Perks
- Remote work arrangement.
- 12-month contract with potential for conversion.
- Minimal weekend on-call coverage.
- Opportunity to work across commercial, Medicare Advantage, FEP, and appeals lines of business.