Physicians in this role conduct real-time utilization management reviews for home health services, using medical judgment and evidence-based guidelines to determine medical necessity across pre-service, concurrent, retroactive, and claims reviews. The work also includes peer-to-peer discussions, quality issue review, and documentation of utilization concerns. It is a fully remote role with flexible hours and regular collaboration with health plan, provider, and interdisciplinary team stakeholders.
Key Responsibilities
- Conduct focused case reviews in the software system to assess medical necessity for home health services.
- Apply evidence-based clinical guidelines to pre-service, concurrent, retroactive, and claims reviews.
- Provide peer-to-peer consultations with payer medical directors, primary care physicians, hospitalists, and specialists.
- Review and document potential quality issues and areas of inappropriate resource utilization.
- Participate in inter-rater review cases and interdisciplinary team meetings.
- Provide medical guidance for utilization management, quality improvement, and clinical review activities.
- Assist with policy review, clinical content input, and regulatory/compliance activities.
- Support efforts to improve care quality, reduce unwarranted variation, and address return-to-acute concerns.
Required
- MD or DO license in good standing with no restrictions in the state where reviews are conducted.
- Board certification, preferably in a primary care specialty such as Internal Medicine, Family Medicine, Geriatrics, or Physical Medicine and Rehabilitation.
- Actively practicing physician with at least 10 years of clinical experience.
- Board certification through the American Board of Medical Specialties.
Preferred
- Experience conducting utilization management authorization and determination reviews in a health plan or IPA setting.
- Experience with peer-to-peer meetings.
- Experience with Medicare Advantage, Medicare, or Medicaid populations.
- Experience using Milliman Care Guidelines or InterQual.
- Coursework in health administration, health financing, or insurance.
- Knowledge of CMS Chapter 7 Home Health guidelines.
Benefits & Perks
- Fully remote work arrangement.
- Flexible hours.
- Opportunity to work with proprietary technology and established processes.
- Collaboration with a multidisciplinary clinical and medical management team.