Top 49522 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
Quick Apply
Senior Manager, Utilization Management
1199SEIU Family of Funds —New York, NY
- $125,400 - $156,700 a year
- Full-time
- Nursing
- 6 years
- RN License
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)
Quick Apply
1d
Manager, Utilization Review
Health Business Solutions LLC —Remote
- Nursing
- RN License
- Mid-level
8d
Clinical Manager, Global
Spring Health —Remote
- $97,325 - $114,500 a year
- Full-time
- Remote
- LMFT
- Licensed Clinical Social Worker
- 3 years
- Health savings account
- Health insurance
Quick Apply
Regulatory Process Manager (IDRE)
PROVIDER RESOURCES INC —Remote
- $125,000 - $175,000 a year
- Full-time
- Remote
- Continuous improvement
- Training & development
- Senior level
Quick Apply
Pharmacy Operations Manager (Remote)
MRIoA —Remote
- Full-time
- Remote
- Background check
- Pass drug screening
- Supervising experience
- Paid holidays
- Health insurance
Quick Apply
Care Manager, Concurrent Review (Remote)
EmblemHealth —New York, NY
- $68,040 - $118,800 a year
- Remote
- Nursing
- Microsoft Outlook
- RN License
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
Clinic Engagement Manager
THE MAVEN PROJECT —Remote
- $60,000 - $70,000 a year
- Full-time
- Remote
- Microsoft Excel
- Microsoft Outlook
- Computer literacy
Quick Apply
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 Management Manager Full Time
Kindred Hospitals Mountain District Office —Las Vegas, NV
- Full-time
- Nursing
- Microsoft Outlook
- Hospital
Utilization Review Specialist
Charlie Health —Nashville, TN
- Full-time
- Remote
- HIPAA
- Mid-level
- High school diploma or GED
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
Stakeholder Engagement Manager (IDRE)
PROVIDER RESOURCES INC —Remote
- $125,000 - $175,000 a year
- Full-time
- Remote
- Senior level
- Commercial
Quick Apply
Director, ICU/Pathology - SMG
SMG System Medical Group —Morgantown, WV
- Overtime
- Hybrid work
- Hospital
- Urgent Care
- Master's degree
Nurse Manager | Medical Oncology & Medical Specialties
Concord Hospital —Concord, NH
- Full-time
- Acute care
- Nursing
- RN License
- Disability insurance
- 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
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)

Utilization Review Coordinator

Senior Manager, Utilization Management

Care Manager - Utilization Management (Must Have UAS Experience)

Utilization Management Clinician I

Utilization Review Manager

Manager, Utilization Review

Clinical Manager, Global

Regulatory Process Manager (IDRE)

Pharmacy Operations Manager (Remote)

Care Manager, Concurrent Review (Remote)

Utilization Review Specialist

Clinic Engagement Manager

Virtual Reimbursement Manager

Utilization Management Manager Full Time

Utilization Review Specialist

Program Manager EHR Trainer

Stakeholder Engagement Manager (IDRE)

Director, ICU/Pathology - SMG

Nurse Manager | Medical Oncology & Medical Specialties

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