Remote Utilization Review Physician Reviewer

About This Role

This remote Physician Reviewer role involves assessing requests for medical care against guidelines and company policies, ensuring clear communication of decisions, and collaborating with medical professionals to determine appropriate treatments for a leading health insurance company.

Responsibilities

• Review requests for care before, during, and after treatment to confirm adherence to medical guidelines and company policies
• Check different types of services including hospital stays, rehab care, medical equipment, and outpatient treatments
• Document decisions clearly for member understanding and consistency using templates
• Communicate directly with doctors to explain decisions or suggest alternative treatments based on medical evidence
• Meet deadlines, follow all laws and regulations, and handle related tasks as needed

Requirements

• Board certification as an MD or DO
• 5-6+ years of clinical practice experience
• 1+ years of utilization review experience in a managed care plan (payer side not clinical)
• Licensed in FL or NC, TX, or MO and/or active Interstate Medical Licensure Compact (IMLCC) or eligible to apply for IMLCC

Qualifications

• 5-6+ years of clinical practice experience and 1+ years of utilization review experience in a managed care plan (payer side)

Nice to Have

• Specialty in Cardiology OR Neurology

Benefits

Certifications