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Role Description

As the Utilization Management (UM) Physician Reviewer, you will report to the Medical Director of UM and provide clinical expertise to ensure high-quality, medically necessary, and efficient patient care aligned with regulatory requirements. This role involves making direct decisions in prior authorization, concurrent review of hospitalized patients, and discharge planning.

• Clinical review of prior authorization, concurrent review, and retrospective review requests using critical thinking and established guidelines.
• Interpreting benefit language and ensuring accurate documentation.
• Engaging in peer-to-peer discussions with providers and collaborating with other healthcare professionals.
• Handling appeals and grievances while ensuring compliance with federal, state, and accreditation standards.
• Acting as a clinical liaison and participating in case reviews and fair hearing processes.
• Identifying utilization trends and contributing to policy development and quality improvement.
• Guiding UM nurses and clinical staff while staying current with evidence-based medical literature and healthcare trends.

This position is remote, but will be expected to work PST business hours.

This position is part-time, working approximately 20 hours/week, with flexible days/hours. The schedule includes weekend and holiday rotations ensuring coverage for urgent reviews.

Qualifications

• Clear and current California MD or DO license.
• Proficiency in using electronic health records and UM software platforms (after training).

Requirements

• 2+ years of experience in a direct patient care setting, Primary care specialty preferred.
• Experience in utilization management, medical review, or managed care setting preferred.
• Strong knowledge of clinical standards of care, NCQA requirements, CMS guidelines, and Medicaid / Medicare programs and dual eligible populations, and benefit systems preferred.

Benefits

• Competitive pay with a flexible Health & Welfare benefits package.
• Cafeteria-style benefit program allowing employees to choose benefits from various options, including medical, dental, and vision plans for employees and their dependents.
• Health Spending Account (HSA), Life Insurance, and Long Term Disability.
• 401k retirement plan with a generous employer-match.
• Paid Time Off and Sick Leave.