Top 688 Utilization Reviewer 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
Utilization Reviewer (FT)
Rehabilitation Hospital of Indiana —Indianapolis, IN
- Full-time
- Hospital
- Mid-level
- 3 years
- Tuition reimbursement
- 401(k) matching
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13d
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
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Physician Reviewer - Utilization Management (Part Time)
Oscar Health —New York, NY
- $130 - $145 an hour
- Part-time
- Remote
- Medicine
- BC/BE
- Travel
- Paid parental leave
- Paid holidays
Quick Apply
11h
Endocrinologist - Independent Reviewer for Disability Appeals
Emperion —Remote
- $100 - $1,000 an hour
- Part-time
- Remote
- Mid-level
- 3 years
- Communication skills
Quick Apply
Physician Reviewer - Physical Medicine and Rehabilitation (Utilization Review)
Dane Street, LLC —New York, NY
- Remote
- Physical & Rehabilitation Medicine
- Mid-level
Quick Apply
Remote Home Health RN – Medical Claims Reviewer
Broadway Ventures —Remote
- $60,000 - $63,000 a year
- Full-time
- Remote
- Nursing
- RN License
- Customer service
Quick Apply
Fleet Manager
Vista Trans Holding —Lake in the Hills, IL
- $1,800 - $2,000 a week
- Full-time
- Background check
- 5 years
- Bachelor's degree
Quick Apply
Oncology Nurse Navigator – Physician Aligned, BMG Oncology Elkhart, Full-time Days
Beacon Health System —Elkhart, IN
- Full-time
- Nursing
- RN License
- Mid-level
- 403(b) matching
- Health insurance
Quick Apply
BCBA Clinical Director
GBE Alliance —Hopkinsville, KY
- Full-time
- Background check
- 3 years
- Master's degree
- Paid holidays
- Dental insurance
Quick Apply
OASIS Workflow Coordinator Weekend (RN, Registered Nurse, Home Health) - HomeCare
Hartford HealthCare at Home —Mansfield Center, CT
- Part-time
- Nursing
- RN License
- Writing skills
Quick Apply
Clinical Leader/Assistant Nurse Manager RN (ICU/CCU & Stepdown) - Nights
CentraState Healthcare System —Freehold, NJ
- $107,250 - $182,330 a year
- Full-time
- Acute care
- Nursing
- RN License
- 403(b) matching
- AD&D insurance
Utilization Review Manager
Forest View Hospital —Grand Rapids, MI
- Full-time
- Management
- Psychiatry
- RN License
- Continuing education credits
- Health savings account
Quick Apply
Clinical Reviewer (BHJOB1435_35508)
Astyra Corporation —Indianapolis, IN
- $38 - $40 an hour
- Weekends as needed
- Remote
- Background check
- Nursing
- LVN
- Health insurance
- Dental insurance
Quick Apply
5d
Referral Management (Non-Nurse) Reviewer
Zimmerman Associates, Inc. —Bethesda, MD
- $23.56 an hour
- Microsoft Excel
- Microsoft Outlook
- Mid-level
Medical Director -- Part Time Contracted
Ventura County Health Care Plan —Oxnard, CA
- $156,000 - $195,000 a year
- Part-time
- Medicine
- BC/BE
- 3 years
Quick Apply
Utilization Management Clinical Reviewer
CuraFi —San Francisco, CA
- $140,000 - $160,000 a year
- Full-time
- Hybrid work
- RN License
- Senior level
- Communication skills
- Health insurance
- Dental insurance
Quick Apply
5d
Therapist (AMFT, ASW, APCC) Santa Clarita - Mental Health and Substance Use
Santa Clarita Behavioral Health —Valencia, CA
- $33 - $40 an hour
- Part-time
- Background check
- Computer literacy
- Mid-level
- Health insurance
- Dental insurance
Quick Apply
Legal Nurse / Case Review Nurse - Onsite | FL Licensed | Ortho/Neuro
Shimspine —Oldsmar, FL
- $25 - $38 an hour
- Full-time
- Google Workspace
- Nursing
- RN License
- Profit sharing
- Disability insurance
Quick Apply
12d
Licensed Physician Reviewer-GI (remote)
ChenMed —Miami, FL
- $204,761 - $292,515 a year
- Full-time
- Remote
- Medicine
- Microsoft Excel
- Microsoft Outlook
- Opportunities for advancement

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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 Reviewer jobs

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Utilization Review Specialist

Physician Reviewer - Utilization Management (Part Time)

Endocrinologist - Independent Reviewer for Disability Appeals

Physician Reviewer - Physical Medicine and Rehabilitation (Utilization Review)

Remote Home Health RN – Medical Claims Reviewer

Fleet Manager

Oncology Nurse Navigator – Physician Aligned, BMG Oncology Elkhart, Full-time Days

BCBA Clinical Director

OASIS Workflow Coordinator Weekend (RN, Registered Nurse, Home Health) - HomeCare

Clinical Leader/Assistant Nurse Manager RN (ICU/CCU & Stepdown) - Nights

Utilization Review Manager

Clinical Reviewer (BHJOB1435_35508)

Referral Management (Non-Nurse) Reviewer

Medical Director -- Part Time Contracted

Utilization Management Clinical Reviewer

Therapist (AMFT, ASW, APCC) Santa Clarita - Mental Health and Substance Use

Legal Nurse / Case Review Nurse - Onsite | FL Licensed | Ortho/Neuro

Licensed Physician Reviewer-GI (remote)

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