Specialty Physician Reviewer – Utilization Management (UM)

The Physician Reviewer serves as a clinical subject matter expert in the Utilization Management (UM) department. This role is responsible for conducting clinical reviews of medical necessity, appropriateness of care, and service requests based on evidence\-based guidelines, medical policy, and regulatory requirements. The Physician Reviewer collaborates with UM nurses, medical directors, and other healthcare professionals to ensure appropriate, timely, and cost\-effective care for members. **Key Responsibilities:** * Conduct physician\-level reviews of prior authorization, concurrent review, and retrospective review cases across multiple lines of business (e.g., commercial, Medicaid, Medicare). * Apply nationally recognized clinical criteria (e.g., MCG, InterQual), internal medical policies, and applicable regulations (CMS, NCQA, URAC) to review determinations. * Render clinical decisions in a timely manner consistent with regulatory timeframes and health plan policies. * Collaborate with medical directors, case managers, and care teams to support optimal care pathways. * Participate in audits, appeals, and grievance processes as needed. * Maintain current knowledge of clinical best practices, industry trends, and regulatory changes. * Participate in peer\-to\-peer discussions with attending physicians to communicate UM decisions and promote evidence\-based care. * Analyze clinical data and documentation to support accurate determinations and appeals. * Contribute to the development and refinement of clinical policies and UM protocols specific to the specialized care. * Provide guidance on clinical appropriateness, benefit coverage, and policy interpretation. * Provide education and clinical support to internal teams and external providers regarding best practices and clinical pathways. * Ensure compliance with regulatory, accreditation, and legal requirements in all UM activities. * Ensure adherence to all HIPAA, confidentiality, and privacy standards. * Participate in quality improvement initiatives and clinical case rounds. **Qualifications:** * Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree required. * Active and unrestricted medical license. * Minimum of 5 years of clinical practice experience in the respective specialty. * At least 3 years of experience in Utilization Management within a health plan. * Familiarity with evidence\-based guidelines and UM tools (e.g., InterQual, MCG). * Strong communication and documentation skills. * Proficiency with electronic medical records and clinical review platforms. * Experience with Medicare/Medicaid and commercial insurance regulations is preferred. **Board certification in one of the following specialties:** * Vascular * Orthopedics * Radiology * Oncology * Ophthalmology * Cardiology * Nephrology * Neurology * Pulmonology **Preferred Skills:** * Experience with Medicare and/or Medicaid managed care plans * Knowledge of medical necessity appeal processes and peer review protocols. * Knowledge of CMS, NCQA, and/or URAC standards * Previous peer review or medical director experience * Comfortable working in a remote, collaborative environment. Job Type: Contract Work Location: Remote