Physician Reviewer – Utilization Management (Remote) 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
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