Specialty Physician Reviewer – Utilization Management (UM) at Toney HealthCare Consulting LLC
Remote, Oregon, USA -
Full Time


Start Date

Immediate

Expiry Date

11 Nov, 25

Salary

0.0

Posted On

11 Aug, 25

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

No

Skills

Care Plans, Cms, Utilization Management, Medicaid, Medical Records, Medicare, Collaborative Environment, Medicine

Industry

Pharmaceuticals

Description

The Physician Reviewer serves as a clinical subject matter expert in the Utilization Management (UM) department. This role is responsible for conducting clinical reviews of medical necessity, appropriateness of care, and service requests based on evidence-based guidelines, medical policy, and regulatory requirements. The Physician Reviewer collaborates with UM nurses, medical directors, and other healthcare professionals to ensure appropriate, timely, and cost-effective care for members.

QUALIFICATIONS:

  • Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree required.
  • Active and unrestricted medical license.
  • Minimum of 5 years of clinical practice experience in the respective specialty.
  • At least 3 years of experience in Utilization Management within a health plan.
  • Familiarity with evidence-based guidelines and UM tools (e.g., InterQual, MCG).
  • Strong communication and documentation skills.
  • Proficiency with electronic medical records and clinical review platforms.
  • Experience with Medicare/Medicaid and commercial insurance regulations is preferred.

PREFERRED SKILLS:

  • Experience with Medicare and/or Medicaid managed care plans
  • Knowledge of medical necessity appeal processes and peer review protocols.
  • Knowledge of CMS, NCQA, and/or URAC standards
  • Previous peer review or medical director experience
  • Comfortable working in a remote, collaborative environment.
    Job Type: Contract
    Expected hours: 20 – 40 per week
    Work Location: Remot
Responsibilities
  • Conduct physician-level reviews of prior authorization, concurrent review, and retrospective review cases across multiple lines of business (e.g., commercial, Medicaid, Medicare).
  • Apply nationally recognized clinical criteria (e.g., MCG, InterQual), internal medical policies, and applicable regulations (CMS, NCQA, URAC) to review determinations.
  • Render clinical decisions in a timely manner consistent with regulatory timeframes and health plan policies.
  • Collaborate with medical directors, case managers, and care teams to support optimal care pathways.
  • Participate in audits, appeals, and grievance processes as needed.
  • Maintain current knowledge of clinical best practices, industry trends, and regulatory changes.
  • Participate in peer-to-peer discussions with attending physicians to communicate UM decisions and promote evidence-based care.
  • Analyze clinical data and documentation to support accurate determinations and appeals.
  • Contribute to the development and refinement of clinical policies and UM protocols specific to the specialized care.
  • Provide guidance on clinical appropriateness, benefit coverage, and policy interpretation.
  • Provide education and clinical support to internal teams and external providers regarding best practices and clinical pathways.
  • Ensure compliance with regulatory, accreditation, and legal requirements in all UM activities.
  • Ensure adherence to all HIPAA, confidentiality, and privacy standards.
  • Participate in quality improvement initiatives and clinical case rounds.
Loading...