Top 49578 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
4d
Clinical Operations Manager
PWP Health —Illinois
- $110,500 - $120,000 a year
- Full-time
- 5 years
- Bachelor's degree
- Psychology
- Health insurance
- Dental insurance
Quick Apply
Senior Director, Provider Contracting - Denver Health Medical Plan (Must Live in Colorado. Weekly On-Site Requirement)
Denver Health —Denver, CO
- $143,800 - $237,400 a year
- Full-time
- Hybrid work
- Pass drug screening
- Office
- Finance
- Paid parental leave
- Paid holidays
RN Case Manager
AMN Healthcare —Salem, MA
- $1,800 - $2,700 a week
- Part-time
- RN License
- BLS Certification
- Acute care experience
- Paid jury duty
- Paid holidays
11d
Clinical Documentation Improvement (CDI) Manager
University Medical Center of Southern Nevada —Las Vegas, NV
- $90,584.00 - $144,934.40 a year
- Full-time
- Nursing
- Management
- Hospital
- Free parking
- Relocation assistance
Quick Apply
Program Manager EHR Trainer
SCA Health —Remote
- $112,000 - $125,000 a year
- Full-time
- 3 years
- Continuous improvement
- Mentoring
- Disability insurance
- Health insurance
11d
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
Utilization Review Nurse
Cobalt Benefits Group LLC —Dallas, TX
- $90,000 - $98,000 a year
- Full-time
- Remote
- Nursing
- Microsoft Excel
- Microsoft Outlook
- Health savings account
- AD&D insurance
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
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
Senior Manager, Utilization Management
1199SEIU Family of Funds —New York, NY
- $125,400 - $156,700 a year
- Full-time
- Nursing
- 6 years
- RN License
RN Case Manager
MedStar Health —Washington, DC
- $89,065 - $162,801 a year
- Full-time
- Nursing
- Microsoft Excel
- RN License
Field RN Case Manager
MedStar Health —Washington, DC
- $89,065 - $162,801 a year
- Full-time
- Nursing
- Management
- RN License
13d
RN Case Manager - Complex Cases
UCLA Health —Santa Monica, CA
- $65.53 - $84.75 an hour
- Nursing
- RN License
- BLS Certification
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
Case Manager
SSM Health Rehabilitation Hospital —St. Louis, MO
- $77,000 - $105,000 a year
- 8 hour shift
- RN License
- Hospital
- Inpatient
- Dental insurance
- Paid time off
Quick Apply
14d
Manager, Optimization
Oscar Health —Atlanta, GA
- $105,818.40 - $138,886.65 a year
- Overtime
- Remote
- Mid-level
- 3 years
- Master's degree
- Paid parental leave
- Paid holidays
Quick Apply
12d
Care Manager, Concurrent Review (Remote)
EmblemHealth —New York, NY
- $68,040 - $118,800 a year
- Remote
- Nursing
- Microsoft Outlook
- RN License
Manager, Utilization Review
Health Business Solutions LLC —Remote
- Nursing
- RN License
- Mid-level
7d
Denial & Appeals Coordinator, Remote
Baptist Health South Florida —Florida
- $87,755.20 - $116,714.42 a year
- Remote
- Nursing
- RN License
- Research
- Wellness program
- Health insurance

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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
4 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)

Clinical Operations Manager

Senior Director, Provider Contracting - Denver Health Medical Plan (Must Live in Colorado. Weekly On-Site Requirement)

RN Case Manager

Clinical Documentation Improvement (CDI) Manager

Program Manager EHR Trainer

Director, Utilization Management Operations

Utilization Review Nurse

Sr. Manager of Member Engagement

Denials & Appeals Administrator (RN)

Senior Manager, Utilization Management

RN Case Manager

Field RN Case Manager

RN Case Manager - Complex Cases

Care Manager - Utilization Management (Must Have UAS Experience)

Case Manager

Manager, Optimization

Care Manager, Concurrent Review (Remote)

Manager, Utilization Review

Denial & Appeals Coordinator, Remote

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