Lead utilization review for Commercial and Medicare Advantage members, focusing on inpatient admissions, continued stays, and post-acute services such as SNF, IRF, LTACH, and home health. Evaluate medical necessity and level-of-care appropriateness using evidence-based criteria, benefit plans, and CMS standards, and serve as the physician reviewer for complex or escalated cases. Collaborate with utilization management, care management, and treating physicians to support consistent decisions, documentation, and care transitions.
Key Responsibilities
- Conduct timely medical necessity reviews for inpatient and post-acute care settings.
- Assess acute and post-acute services using MCG, InterQual, CMS criteria, and plan-specific coverage guidelines.
- Serve as physician reviewer for escalated, complex, or potentially adverse utilization management cases.
- Participate in peer-to-peer discussions with attending and treating physicians.
- Collaborate with utilization management and care management teams on care decisions and transitions.
- Identify utilization trends and support efforts to reduce avoidable admissions, readmissions, and extended stays.
- Provide input on medical policies, clinical guidelines, and utilization management protocols.
- Document reviews and clinical rationales in compliance with regulatory and organizational requirements.
Required
- MD or DO degree.
- Active, unrestricted medical license in the state of residence.
- Current board certification in an appropriate medical specialty.
- At least 5 years of clinical experience.
- At least 3 years of experience in utilization management, physician review, or medical leadership in a managed care or health plan setting.
- Experience supporting Commercial and/or Medicare Advantage populations.
Preferred
- MPH, MBA, or MHA.
- Board certification from the American Board of Quality Assurance and Utilization Review Physicians.
Benefits & Perks
- Physician leadership role reporting to the Chief Medical Officer.
- Opportunity to work across Commercial and Medicare Advantage utilization management.
- Work involving evidence-based clinical criteria and population health data.
- Exposure to committee work and external stakeholder engagement.