Top 54701 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
5d
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
Utilization Management Clinician I
Community Health Plan of Washington —Seattle, WA
- $35.92 - $55.67 an hour
- Full-time
- Mid-level
- Analysis skills
- Critical & Intensive Care
- Paid jury duty
- Health savings account
Quick Apply
Utilization Review Manager
Assurance Health System, LLC —Remote
- Full-time
- Remote
- Management
- Psychiatry
- RN License
- Health insurance
- 401(k)
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1d
Manager, Utilization Review
Health Business Solutions LLC —Remote
- Nursing
- RN License
- Mid-level
8d
Account Manager - B2B Sales
Used Cardboard Boxes Inc. —Remote
- $90,000 - $300,000 a year
- Full-time
- Remote
- Mid-level
- Travel
- 2 years
- Paid holidays
- Health insurance
Quick Apply
Supply Planning Manager
Industrial Electric Manufacturing —Remote
- $129,529 - $166,400 a year
- Remote
- 5 years
- Analysis skills
- Bachelor's degree
Quick Apply
Client Success Manager
Included Health —Remote
- $93,850 - $122,856 a year
- Full-time
- 5 years
- Urgent Care
- Travel
- Paid parental leave
- Disability insurance
Quick Apply
Director, Utilization Management Operations
Devoted Health —Remote
- $182,000 - $248,000 a year
- Full-time
- Remote
- Travel
- In-person
- Senior level
- Dental insurance
- 401(k)
12d
Clinic Engagement Manager
THE MAVEN PROJECT —Remote
- $60,000 - $70,000 a year
- Full-time
- Remote
- Microsoft Excel
- Microsoft Outlook
- Computer literacy
Quick Apply
Purchasing & Inventory Manager
Engineered Products —Remote
- Remote
- 5 years
- Mid-level
- Analysis skills
Quick Apply
Sales Operations Manager
OpenSesame —Remote
- $100,000 - $120,000 a year
- Remote
- Continuous improvement
- Senior level
- Health insurance
- Paid time off
Quick Apply
Customer Success Manager
Alpaca Health —New York State
- $80,000 - $160,000 a year
- Full-time
- Remote
- Mid-level
- Health insurance
- Paid time off
Quick Apply
Platform Success Manager
AHEAD —Remote
- $110,000 - $120,000 a year
- Full-time
- Remote
- Mid-level
- Analysis skills
- Training & development
- Paid parental leave
- Paid holidays
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
Head of Human Resources (Remote)
BOOST LLC —Remote
- $135,000 - $150,000 a year
- Full-time
- Remote
- 8 years
- US work authorization
- Senior level
- Dental insurance
- 401(k)
Quick Apply
13d
Care Manager, Concurrent Review (Remote)
EmblemHealth —New York, NY
- $68,040 - $118,800 a year
- Remote
- Nursing
- Microsoft Outlook
- RN License
Program Manager - Cardiac Rehabilitation
SouthEast Alaska Regional Health Consortium —Juneau, AK
- $36.46 - $51.29 an hour
- Full-time
- Microsoft Excel
- Computer literacy
- BLS Certification
- Paid parental leave
- Disability insurance
Quick Apply
Director, ICU/Pathology - SMG
SMG System Medical Group —Morgantown, WV
- Overtime
- Hybrid work
- Hospital
- Urgent Care
- Master's degree
Supervising Pharmacist
Integrea Community Mental Health Systems —Opelika, AL
- Extended hours
- Bachelor of Science
- Residential
- Bachelor's degree
- Dental insurance
- Vision insurance
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
5 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)

Utilization Management Clinician I

Utilization Review Manager

Manager, Utilization Review

Account Manager - B2B Sales

Supply Planning Manager

Client Success Manager

Director, Utilization Management Operations

Clinic Engagement Manager

Purchasing & Inventory Manager

Sales Operations Manager

Customer Success Manager

Platform Success Manager

Utilization Review Specialist

Head of Human Resources (Remote)

Care Manager, Concurrent Review (Remote)

Program Manager - Cardiac Rehabilitation

Director, ICU/Pathology - SMG

Supervising Pharmacist

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