In this remote utilization review role, the physician reviews medical services, procedures, and hospital admissions to determine medical necessity and appropriate coverage. The work includes peer-to-peer discussions with treating clinicians, appeals review, and interpretation of evidence-based guidelines and health plan policies. The role also supports policy development, quality oversight, and clinical consultation to improve outcomes and manage care cost-effectively.
Key Responsibilities
- Conduct reviews of medical services, procedures, and hospital admissions for medical necessity and coverage decisions.
- Provide peer-to-peer consultations with attending physicians and ordering providers to clarify documentation and review determinations.
- Interpret medical policies, clinical guidelines, and regulatory requirements to support consistent decision-making.
- Review and adjudicate member and provider appeals for previously denied services.
- Collaborate with clinical committees to develop, update, and implement medical policies and clinical programs.
- Advise internal teams on cost-of-care opportunities, clinical operations, and health outcome improvement.
- Participate in quality committees to align utilization management activities with contractual, regulatory, and accreditation standards.
Required
- MD or DO degree from an accredited institution.
- Board certification in Internal Medicine, Family Medicine, or Emergency Medicine through ABMS or AOA.
- Active, unrestricted medical license in New York, Pennsylvania, or West Virginia.
- At least 6 years of clinical experience, or an equivalent combination of residency and experience.
- Experience in utilization review for a health plan.
Preferred
- Experience using MCG or InterQual guidelines.
Benefits & Perks
- Remote work anywhere in the U.S.
- Full-time contract role with long-term, no pre-determined end date.
- Medical insurance options, including PPO or HCHP coverage.
- Vision and dental coverage.
- 401(k) plan.
- Additional voluntary benefits.
- Hourly rate of $135 to $150, depending on location and experience.