Top 2626 Compliance Process Reviewer Jobs

Utilization Management Physician Reviewer (Weekends)
Toney HealthCare Consulting, LLC —Remote
- $175 - $200 an hour
- Part-time
- Remote
- Medicine
- 3 years
- Senior level
- Health insurance
Quick Apply
6d
Manager of Compliance Audit
PROVIDER RESOURCES INC —Remote
- $105,000 - $155,000 a year
- Full-time
- Remote
- 5 years
- Senior level
- Analytics
Quick Apply
Sports Action Recognition Reviewer (AI Data Annotation)
e2f, inc. —Remote
- Remote
- Mid-level
Quick Apply
Clinical Study Data Reviewer
IUVO BIOSCIENCE OPERATIONS, LLC —Remote
- $60,000 - $74,000 a year
- Remote
- Computer literacy
- Writing skills
- HIPAA
Quick Apply
14d
Online Sweepstakes Reviewer (Remote) - Paid Contract Position
Signup Expert —Salt Lake City, UT
- Contract
- Remote
- Research
- Communication skills
- Entry level
Quick Apply
Contract Support, GlobalG.A.P. Audit Report Technical Reviewer
SCS Global Services —Remote
- Contract
- Mid-level
- Analysis skills
Quick Apply
Online Casino Reviewer (Remote) - Paid Contract Position
Signup Expert —Kansas City, MO
- Contract
- Remote
- Research
- Communication skills
- Entry level
Quick Apply
Nurse Reviewer
Staffing Solutions Organization LLC —Remote
- $73,000 - $83,000 a year
- Full-time
- Remote
- Experience working with individuals with developmental disabilities
- Nursing
- Microsoft Outlook
- Paid holidays
- Health insurance
Quick Apply
Engineer III - EDI
Inland Empire Health Plan —Rancho Cucamonga, CA
- $118,601.60 - $157,144.00 a year
- Full-time
- Hybrid work
- Microsoft Excel
- 6 years
- HIPAA
- Paid holidays
- Disability insurance
Technical Reviewer & Auditor – Meat, Dairy & Food Manufacturing
IFANCA —Des Plaines, IL
- $60,000 - $75,000 a year
- Full-time
- Up to 50% travel
- Customer service
- Mid-level
- Paid holidays
- Health insurance
Quick Apply
Physician - Internal Medicine
Loyal Source Government Services —El Paso, TX
- $200 an hour
- Full-time
- CPR Certification
- Medicine
- Microsoft Excel
Quick Apply
Director of Compliance
Precision Armament —Wellsville, NY
- $65,000 - $90,000 a year
- Full-time
- Management
- 5 years
- Engineering
- Profit sharing
- Health savings account
Quick Apply
21h
RN Clinical Reviewer (CPC Medical Coding Academy) - San Juan, PR
UnitedHealth Group —San Juan, PR
- Full-time
- RN License
- Pass drug screening
- Research
Inpatient DRG Reviewer
Zelis —Saint Petersburg, FL
- $79,000 - $99,750 a year
- Full-time
- Hybrid work
- LVN
- RN License
- Mid-level
- Paid holidays
- Disability insurance
Tax Manager
Weber and Company, Inc. —San Jose, CA
- $125,000 - $185,000 a year
- Full-time
- Hybrid work
- Background check
- CPA
- Research
- Continuing education credits
- Paid holidays
Quick Apply
Physician - Pediatrician
East Valley Community Health Center Inc. —Pomona, CA
- $240,000 - $267,372 a year
- CPR Certification
- Medicine
- BLS Certification
Quick Apply
Senior Appraisal Reviewer - Mortgage
HCLTech —San Antonio, TX
- $24 - $25 an hour
- Email
- Mid-level
- Office
- Residential
- Health savings account
- AD&D insurance
Quick Apply
Director, US Medical Information & Medical Review
BioNTech AG —Berkeley Heights, NJ
- $168,100 - $268,700 a year
- Full-time
- Background check
- Medicine
- 8 years
- Health savings account
- AD&D insurance
Test Verification Engineer
Socomec, Inc. —Longmont, CO
- $80,000 - $90,000 a year
- Full-time
- Hybrid work
- Laboratory experience
- Mid-level
- 3 years
- Health insurance
- Dental insurance
Quick Apply
5d
Fleet Coordinator
Vista Trans —Huntley, IL
- $78,000 - $83,200 a year
- Full-time
- Background check
- CDL A
- Mid-level
Quick Apply

I want to receive the latest job alert for Compliance Process Reviewer

By signing in to your account, you agree to SimplyHired's Terms of Service and consent to our Cookie and Privacy Policy.

Utilization Management Physician Reviewer (Weekends)

Toney HealthCare Consulting, LLC -
Remote

Quick Apply

Job Details

Part-time | Contract
$175 - $200 an hour
6 days ago

Benefits

Health insurance

Qualifications

Teamwork
Medicare
Electronic health records (EHR) management
Utilization management
Quality improvement
Resource utilization in healthcare
Medical License
Documentation review

Full Job Description

Job Overview

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.

Key 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 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.

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.
Availability to work weekends (part-time or full-time) between 8:00 AM and 5:00 PM ET on Saturdays and/or Sundays is required.

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.

Pay: $175.00 - $200.00 per hour

Application Question(s):

Availability to work weekends (part-time or full-time) between 8:00 AM and 5:00 PM ET on Saturdays and/or Sundays is required.

Experience:

Utilization Management Review: 3 years (Required)
Medicare and/or Medicaid: 2 years (Preferred)

License/Certification:

Board-certified M.D. or D.O. medical license? (Required)

Work Location: Remote

Quick Apply

Refine Your Search

Compliance Process Reviewer jobs

Utilization Management Physician Reviewer (Weekends)

Manager of Compliance Audit

Sports Action Recognition Reviewer (AI Data Annotation)

Clinical Study Data Reviewer

Online Sweepstakes Reviewer (Remote) - Paid Contract Position

Contract Support, GlobalG.A.P. Audit Report Technical Reviewer

Online Casino Reviewer (Remote) - Paid Contract Position

Nurse Reviewer

Engineer III - EDI

Technical Reviewer & Auditor – Meat, Dairy & Food Manufacturing

Physician - Internal Medicine

Director of Compliance

RN Clinical Reviewer (CPC Medical Coding Academy) - San Juan, PR

Inpatient DRG Reviewer

Tax Manager

Physician - Pediatrician

Senior Appraisal Reviewer - Mortgage

Director, US Medical Information & Medical Review

Test Verification Engineer

Fleet Coordinator

I want to receive the latest job alert for Compliance Process Reviewer

Related Searches

Explore jobs in more locations

Job Seeker Tools

Employer Tools

Browse

Stay Connected