Top 44309 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
Utilization Review Coordinator
Skywood Recovery —Augusta, MI
- Full-time
- Nursing
- Addiction Medicine
- Mid-level
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Utilization Management Representative II
Elevance Health —San Antonio, TX
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- Mid-level
- High school diploma or GED
- Analysis skills
- Employee stock purchase plan
- Paid holidays
7d
Senior Manager, Regulatory Compliance
Behavioral Health Systems, Inc. —Birmingham, AL
- $120,000 - $150,000 a year
- Full-time
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- 5 years
- Case management
- Travel
- Health insurance
- Dental insurance
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Plant Manager
CP Flexible Packaging —Placentia, CA
- $180,000 - $200,000 a year
- Senior level
- Leadership
- Communication skills
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Utilization Review Manager
Assurance Health System, LLC —Remote
- Full-time
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- Management
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- RN License
- Health insurance
- 401(k)
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1d
Manager, Utilization Review
Health Business Solutions LLC —Remote
- Nursing
- RN License
- Mid-level
7d
Clinical Manager, Global
Spring Health —Remote
- $97,325 - $114,500 a year
- Full-time
- Remote
- LMFT
- Licensed Clinical Social Worker
- 3 years
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MRIoA —Remote
- Full-time
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- Background check
- Pass drug screening
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Regulatory Process Manager (IDRE)
PROVIDER RESOURCES INC —Remote
- $125,000 - $175,000 a year
- Full-time
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- Continuous improvement
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- Senior level
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Utilization Review Specialist
We Level Up —Pompano Beach, FL
- $50,000 - $90,000 a year
- Full-time
- Remote
- 18 years or older
- CPR Certification
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Clinic Engagement Manager
THE MAVEN PROJECT —Remote
- $60,000 - $70,000 a year
- Full-time
- Remote
- Microsoft Excel
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Care Manager, Concurrent Review (Remote)
EmblemHealth —New York, NY
- $68,040 - $118,800 a year
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- Nursing
- Microsoft Outlook
- RN License
Program Manager EHR Trainer
SCA Health —Remote
- $112,000 - $125,000 a year
- Full-time
- 3 years
- Continuous improvement
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- Disability insurance
- Health insurance
11d
Utilization Management Manager Full Time
Kindred Hospitals Mountain District Office —Las Vegas, NV
- Full-time
- Nursing
- Microsoft Outlook
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Virtual Reimbursement Manager
サイネオス・ヘルス —Seattle, WA
- $140,000 - $150,000 a year
- Mid-level
- Bachelor's degree
- Medical terminology
- Health insurance
- Dental insurance
Utilization Review Specialist
Charlie Health —Nashville, TN
- Full-time
- Remote
- HIPAA
- Mid-level
- High school diploma or GED
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Stakeholder Engagement Manager (IDRE)
PROVIDER RESOURCES INC —Remote
- $125,000 - $175,000 a year
- Full-time
- Remote
- Senior level
- Commercial
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Clinical Operations Manager
PSI CRO —Remote
- Full-time
- Remote
- Medicine
- 5 years
- English
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8d
Customer Success Manager
Insurity —Remote
- $65,000 - $1,109,000 a year
- Call employer
- Remote
- Background check
- Data analysis skills
- English
- Health insurance
- Paid time off

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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

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