100 Remote Utilization Management Role | Primary Care Physician Internal Medicine Physicians Preferred

Position Summary

A leading healthcare organization is seeking a Utilization Management Physician (UMP) for a full-time remote role. This position requires strong clinical judgment critical thinking and effective communication skills. The physician will be responsible for reviewing cases determining medical necessity and supporting evidence-based decision-making within a managed care environment.

Ideal Candidate Profile:
The ideal candidate would preferably be a Primary Care Physician. Alternatively candidates who have completed a 3-year Internal Medicine residency followed by a 12 year specialty fellowship (such as Cardiology Endocrinology Rheumatology Infectious Disease or similar) will also be strongly considered.

Key Responsibilities

• Review pre-authorization requests including initial and concurrent clinical reviews
• Evaluate post-service cases including claims and appeals
• Render determinations based on clinical information and medical necessity using evidence-based guidelines and nationally recognized criteria (e.g. MCG InterQual CMS guidelines)
• Apply internal medical policies and member coverage guidelines to decision-making
• Review and update clinical criteria and decision-support tools annually
• Support provider education on treatment protocols and care pathways
• Provide guidance to utilization management staff on complex cases
• Conduct peer-to-peer discussions with treating providers as needed
• Ensure compliance with regulatory standards for authorization determinations
• Participate in discussions for urgent or escalated cases
• Clearly document rationale for non-certification decisions
• Collaborate with specialty physicians when additional expertise is required
• Participate in internal committees and clinical review initiatives as needed

Qualifications

• MD or DO from an accredited medical school
• Active unrestricted medical license in at least one U.S. state
• Board certification in a primary specialty preferred
• 35 years of clinical experience required
• Minimum 3 years of Utilization Management experience
• Experience within managed care or health plan environments preferred
• Strong understanding of medical policy clinical guidelines and utilization review criteria
• Ability to analyze complex cases and make sound clinical decisions
• Willingness to participate in quality assurance and audit processes

Compensation & Benefits

• Competitive base salary
• Performance-based bonus opportunities
• 401(k) with employer participation
• Comprehensive health benefits for provider and eligible dependents
• Life and disability insurance
• Malpractice insurance coverage
• Paid time off
• CME allowance
• Reimbursement for licenses fees and professional dues
• Travel reimbursement (if applicable)
• Relocation assistance (if applicable)