In this fully remote role, the physician reviewer evaluates acute, post-acute, and pre-service requests to make timely utilization management determinations for older adult Medicare and Medicaid patients. The work focuses on applying clinical judgment and evidence-based criteria to coverage decisions while ensuring recommendations support medically appropriate care. The role also involves close coordination with primary care, transitional care, case management, and external health plan partners.
Key Responsibilities
- Review inpatient and outpatient service requests and document clear decision rationale.
- Use utilization management criteria, clinical reasoning, and individual patient context to support coverage determinations.
- Coordinate with requesting providers, case management staff, transitional care teams, and employed primary care clinicians.
- Maintain knowledge of CMS and MCG evidence-based guidelines for UM decision-making.
- Participate in committees, work groups, and quality improvement efforts related to utilization management.
- Assist with formal responses to health plans regarding UM processes and individual determinations.
- Participate in rounding and patient panel management discussions as needed.
- Adhere to regulatory, accreditation, and payor partner requirements.
Required
- MD or DO degree from an accredited medical school.
- Current unrestricted U.S. medical license.
- At least 1 year of utilization management experience for Medicare and/or Medicaid lines of business.
- 3-5 years of clinical practice in a primary care setting.
- U.S. work authorization.
Preferred
- Experience with managed care, risk arrangements, capitation, peer review, performance profiling, outcome management, care coordination, or pharmacy management.
- Strong verbal and written communication skills.
- Prior experience supporting culturally responsive care.
- Demonstrated organization and attention to detail.
Benefits & Perks
- Fully remote work arrangement.
- Full-time schedule, Monday through Friday, 8am to 5pm.
- Annual base salary of $230,000.
- Medical, dental, and vision coverage.
- Paid time off.
- Retirement savings options.
- Wellness programs and related resources.