Physician Reviewer – Utilization Management (Remote)-Full Time

Overview

We are seeking a Board-Certified Physician to support utilization management activities by reviewing clinical documentation and determining the medical appropriateness of inpatient, outpatient, and pharmacy services. This role plays a critical part in ensuring evidence-based, high-quality, and cost-effective care decisions. The ideal candidate brings strong clinical judgment, experience within managed care, and the ability to apply nationally recognized medical guidelines in a fast-paced, collaborative environment.

Key Responsibilities

• Review and assess medical necessity for inpatient, outpatient, and pharmacy services
• Apply evidence-based guidelines and medical policy to utilization review determinations
• Provide peer-to-peer consultations when required
• Collaborate with care management and clinical teams to support appropriate care delivery
• Ensure compliance with regulatory, accreditation, and internal quality standards
• Accurately document decisions within established systems and turnaround times

Required Qualifications

• MD or DO with active Board Certification
• Active medical license in

FL or NC , and/or participation in the Interstate Medical Licensure Compact (IMLC) or eligibility to apply

• Minimum

6 years of clinical practice experience

• At least

1 year of utilization review experience within a managed care or health plan environment

Preferred Qualifications

• Licensure in multiple states
• Board Certification in

Cardiology, Radiation Oncology, or Neurology

• Experience with care management within the health insurance industry
• Willingness and ability to obtain additional state licenses as needed

Schedule & Call

• Hours:

8:00 AM – 5:00 PM (local time zone)

• Call Rotation:

1 weekend every 16 weeks