Top 50166 Utilization Manager 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
Care Manager - Utilization Management (Must Have UAS Experience)
MetroPlusHealth —New York, NY
- $112,351 a year
- Remote
- RN License
- Physical & Rehabilitation Medicine
- Mid-level
Quick Apply
Care Manager, Concurrent Review (Remote)
EmblemHealth —New York, NY
- $68,040 - $118,800 a year
- Remote
- Nursing
- Microsoft Outlook
- RN License
Nurse Case Manager (Remote Position)
First Choice Health Network Inc —Seattle, WA
- $99,000 - $102,000 a year
- 8 hour shift
- Remote
- Nursing
- Addiction Medicine
- RN License
- Profit sharing
- Wellness program
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Utilization Review Nurse
Cobalt Benefits Group LLC —Orlando, FL
- $90,000 - $98,000 a year
- Full-time
- Remote
- Nursing
- Microsoft Excel
- Microsoft Outlook
- Health savings account
- AD&D insurance
Quick Apply
Oncology Prior Authorization Case Manager, Non-RN - Remote
University of Miami —Miami, FL
- Full-time
- Remote
- Mid-level
- Bachelor's degree
- Experience equivalent to degree accepted
- Health insurance
- Dental insurance
Behavioral Health Utilization Manager (temporary)
WellSense Health Plan —Remote
- $33.41 - $48.56 an hour
- Temporary
- LMFT
- Nursing
- Microsoft Excel
Utilization Review Specialist
We Level Up —Pompano Beach, FL
- $50,000 - $90,000 a year
- Full-time
- Remote
- 18 years or older
- CPR Certification
- HIPAA
Quick Apply
Manager, Utilization Review
Health Business Solutions LLC —Remote
- Nursing
- RN License
- Mid-level
8d
Program Manager EHR Trainer
SCA Health —Remote
- $112,000 - $125,000 a year
- Full-time
- 3 years
- Continuous improvement
- Mentoring
- Disability insurance
- Health insurance
12d
Team Medical Director
Lynn Community Health Center —Lynn, MA
- $120,000 - $250,000 a year
- Spanish
- Certified Nurse Practitioner
- BC/BE
- Health insurance
- Dental insurance
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Registered Nurse - Case Manager
SSM Health —Madison, WI
- Part-time
- Nursing
- RN License
- Hospital
- Paid parental leave
- Health insurance
Manufacturing Engineering Manager
Overhead Door Corporation —Williamsport, PA
- $115,162.51 - $130,765.60 a year
- Full-time
- Background check
- 7 years
- Master's degree
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General Manager
Valley Heating & Cooling —Decatur, AL
- $120,000 - $150,000 a year
- Full-time
- 5 years
- Office
- Residential
- Paid training
- Health savings account
Quick Apply
PACE Medical Director, Jordan Valley Senior Care
Jordan Valley Health —Springfield, MO
- Full-time
- Medicine
- Current TB test
- Computer literacy
- Health savings account
- AD&D insurance
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Regional Clinical Manager
VITRA Health —Boston, MA
- $130,000 - $140,000 a year
- Full-time
- Nursing
- RN License
- Customer service
- Disability insurance
- Health insurance
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Branch Clinical Manager (RN) Home Health
Adaptive Home Health —Detroit, MI
- Full-time
- RN License
- Home Health
- Senior level
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Director, Member Advocate Center
Costco Auto Program —Reno, NV
- $100,000 - $110,000 a year
- Full-time
- 7 years
- Microsoft Outlook
- Bachelor's degree
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Nurse Manager, Behavioral Health Services
Signet Health Corporation —Greensboro, NC
- $110,000 - $120,000 a year
- Full-time
- Nursing
- Psychiatry
- RN License
- Disability insurance
- Health insurance
Manager of Clinical Care Coordination, DME Respiratory
Integrated Home Care Acquisition —Miramar, FL
- Hybrid work
- Nursing
- Master's degree
- Home Health
- Wellness program
- Paid holidays
Quick Apply

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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

Utilization Manager jobs

Utilization Management Physician Reviewer (Weekends)

Care Manager - Utilization Management (Must Have UAS Experience)

Care Manager, Concurrent Review (Remote)

Nurse Case Manager (Remote Position)

Utilization Review Nurse

Oncology Prior Authorization Case Manager, Non-RN - Remote

Behavioral Health Utilization Manager (temporary)

Utilization Review Specialist

Manager, Utilization Review

Program Manager EHR Trainer

Team Medical Director

Registered Nurse - Case Manager

Manufacturing Engineering Manager

General Manager

PACE Medical Director, Jordan Valley Senior Care

Regional Clinical Manager

Branch Clinical Manager (RN) Home Health

Director, Member Advocate Center

Nurse Manager, Behavioral Health Services

Manager of Clinical Care Coordination, DME Respiratory

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