Top 50094 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
2d
Utilization Management Physician Reviewer
Oak Street Health —Illinois
- $174,070 - $374,920 a year
- Full-time
- Remote
- Medicine
- Mid-level
- US work authorization
- Health insurance
- Dental insurance
Senior Manager, Utilization Management
1199SEIU Family of Funds —New York, NY
- $125,400 - $156,700 a year
- Full-time
- Nursing
- 6 years
- RN License
Nurse Case Manager, Utilization Management
1199SEIU Family of Funds —New York, NY
- $89,400 - $106,100 a year
- Full-time
- Nursing
- RN License
- Mid-level
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
Denials & Appeals Administrator (RN)
Boston Medical Center —Remote
- $43.03 - $62.50 an hour
- Full-time
- Remote
- Nursing
- RN License
- 5 years
- Health insurance
- Dental insurance
Care Manager, Concurrent Review (Remote)
EmblemHealth —New York, NY
- $68,040 - $118,800 a year
- Remote
- Nursing
- Microsoft Outlook
- RN License
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
CHS Utilization and Appeals Manager
Catholic Health —Melville, NY
- $110,000 - $150,000 a year
- Nursing
- RN License
- Word processing
- Health insurance
- Tuition reimbursement
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
Sr. Manager of Member Engagement
Private Health Management —Remote
- $120,000 - $180,000 a year
- US work authorization
- Senior level
- Leadership
- Health insurance
- Dental insurance
Quick Apply
Payment Training Manager
Cohere Health —Boston, MA
- $105,000 - $118,000 a year
- Remote
- HIPAA
- English
- 8 years
- Paid parental leave
- Health savings account
Quick Apply
Utilization Management Manager
Healthfirst —New York, NY
- $99,700 - $168,810 a year
- Full-time
- Microsoft Excel
- Microsoft Outlook
- RN License
- Health insurance
- Dental insurance
Utilization Review Coordinator
Prosperous Health —Los Angeles, CA
- $70,000 - $80,000 a year
- Full-time
- Hybrid work
- LMFT
- Licensed Clinical Social Worker
- Mid-level
- Paid holidays
- Health insurance
Quick Apply
10d
Organizational Change Manager
Digineer —Minneapolis, MN
- $82,000 - $185,000 a year
- Full-time
- Senior level
- Leadership
- Communication skills
- Disability insurance
- Health insurance
Consultant – Clinical Performance Improvement (Nursing) – Healthcare
Berkeley Research Group, LLC —Remote
- $90,000 - $135,000 a year
- Full-time
- Remote
- Nursing
- RN License
- Master's degree
Program Manager EHR Trainer
SCA Health —Remote
- $112,000 - $125,000 a year
- Full-time
- 3 years
- Continuous improvement
- Mentoring
- Disability insurance
- Health insurance
9d
Care Manager - Utilization Management (Must Have UAS Experience)
MetroPlus Health Plan —New York, NY
- $112,351 a year
- Full-time
- Remote
- RN License
- Physical & Rehabilitation Medicine
- Mid-level
Clinical Review & Correspondence RN
Cohere Health —Remote
- $31 - $35 an hour
- Full-time
- Remote
- Nursing
- RN License
- Mid-level
- Paid parental leave
- Health savings account
Quick Apply
Health - Network Performance / Utilization Manager
Accenture —Irving, TX
- $87,400 - $293,800 a year
- Full-time
- Bachelor's degree
- Travel
- US work authorization
- Paid holidays
- Disability insurance

I want to receive the latest job alert for Utilization Manager

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

Explore jobs in more locations

Utilization Manager jobs near

Utilization Review Nurse jobs in Illinois

Care Manager jobs in New York, NY

Registered Nurse jobs in Remote

Change Manager jobs in Minneapolis, MN

Training Manager jobs in Boston, MA

Utility Manager jobs in New York, NY

Utilization Review Nurse jobs in Remote

Correspondent jobs in Remote

Performance Improvement Specialist jobs in Remote

Utilization Review Nurse jobs in Pompano Beach, FL

Utilization Review Nurse jobs in Los Angeles, CA

Case Manager jobs in New York, NY

Training Manager jobs in Remote

Prior Authorization Specialist jobs in Miami, FL

Utilization Review Nurse jobs in Alabama

Psychiatric Mental Health Nurse Practitioner jobs in Baton Rouge, LA

Utilization Review Nurse jobs in Riverside, CA

Utilization Review Nurse jobs in Austin, TX

Utilization Review Nurse jobs in Warwick, RI

Utilization Review jobs in Pittsburgh, PA

Utilization Management Physician Reviewer (Weekends)

Toney HealthCare Consulting, LLC -
Remote

Quick Apply

Job Details

Part-time | Contract
$175 - $200 an hour
2 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)

Utilization Management Physician Reviewer

Senior Manager, Utilization Management

Nurse Case Manager, Utilization Management

Care Manager - Utilization Management (Must Have UAS Experience)

Denials & Appeals Administrator (RN)

Care Manager, Concurrent Review (Remote)

Oncology Prior Authorization Case Manager, Non-RN - Remote

CHS Utilization and Appeals Manager

Utilization Review Specialist

Sr. Manager of Member Engagement

Payment Training Manager

Utilization Management Manager

Utilization Review Coordinator

Organizational Change Manager

Consultant – Clinical Performance Improvement (Nursing) – Healthcare

Program Manager EHR Trainer

Care Manager - Utilization Management (Must Have UAS Experience)

Clinical Review & Correspondence RN

Health - Network Performance / Utilization Manager

I want to receive the latest job alert for Utilization Manager

Related Searches

Explore jobs in more locations

Job Seeker Tools

Employer Tools

Browse

Stay Connected