This physician role focuses on electronic utilization management review of escalated cases, using medical policy criteria to determine medical necessity and appropriateness of requested services. The work may include telephonic peer-to-peer discussions, initial determinations, and review of appeals and grievances. In addition to utilization review, the physician serves on a multidisciplinary case and disease management team, advising on high-risk cases and supporting protocol, guideline, and special project work.
Key Responsibilities
- Conduct electronic reviews of escalated cases against medical policy criteria.
- Provide telephonic peer-to-peer consultations when needed to clarify case details.
- Review initial determinations, appeals, grievances, and other assigned cases.
- Compose clear rationales for member and provider determination notifications.
- Participate in multidisciplinary case and disease management huddles and grand rounds.
- Advise the care team on complex and high-risk cases that require physician input.
- Participate in protocol and guideline development to support a consistent review process.
- Actively manage or contribute as a physician subject matter expert on special projects.
Required
- MD or DO degree.
- At least 5 years of clinical direct patient care experience in hospital, outpatient, or private practice settings.
- Board certification in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards.
- Active medical licensure in Pennsylvania, New York, or West Virginia.
Preferred
- Master’s degree in Business Administration, Management, or Public Health.
- Experience in medical management within a health insurance plan.
- Experience using MCG or InterQual criteria.
Benefits & Perks
- 100% remote work.
- Hourly pay of $180-$220.