Provide utilization management oversight and appeal reviews for members across Medicare Advantage, Commercial, and ACA plans, with a focus on medical necessity, adverse determinations, and denial decisions. This engagement includes clinical leadership, same-day expedited and standard appeal turnaround support, and review of services considered experimental, investigational, or unproven. The role works in a structured weekday schedule and uses QuickBase, Microsoft Teams, and Microsoft Office in day-to-day workflow.
Key Responsibilities
- Assist the Chief Medical Officer with oversight of care availability, appropriateness, and medical necessity.
- Participate in clinical decision-making for the utilization management program.
- Review appeals and render denial determinations for services not meeting medical necessity or coverage criteria.
- Manage approximately 5–10 appeals per day while meeting expedited and standard turnaround requirements.
- Sign off on adverse determinations in accordance with regulatory and quality standards.
- Support multiple lines of business, including Medicare Advantage, Commercial, and ACA plans.
- Use QuickBase, Microsoft Teams, and Microsoft Office Suite to complete reviews and documentation.
Required
- MD or DO degree.
- Active, unrestricted Wisconsin medical license.
- Experience supporting Medicare Advantage, Commercial, and ACA lines of business.
- Availability to work Monday through Friday, 8 AM to 5 PM CST.
- Proficiency with QuickBase, Microsoft Teams, and Microsoft Office Suite.
Preferred
- Experience in utilization management oversight.
- Experience with appeals review and adverse determination processes.
- Experience making medical necessity determinations.
- Strong familiarity with regulatory compliance and quality standards.
Benefits & Perks
- W2 contract engagement with potential for extension based on business needs.
- Medical, dental, and vision insurance.
- 401(k) retirement savings plan.
- Referral bonus opportunity for eligible colleague referrals.
- Hourly pay range of $150–$180 per hour.