Top 2476607 Qualifications 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
Licensed Appeal Writer - Remote
Med-Metrix —Remote
- $75,000 - $85,000 a year
- Full-time
- Remote
- RN License
- Customer service
- Physical & Rehabilitation Medicine
Agent
Pinkerton —Milwaukee, WI
- Part-time
- Military
- Computer literacy
- Mid-level
Pharmacovigilance Agreements Contractor
Kaztronix —Iselin, NJ
- Contract
- Microsoft Excel
- Microsoft Outlook
- English
Quick Apply
Engineer - Degreed II
Experis —Irvine, CA
- $23 - $27 an hour
- Contract
- Remote
- Engineering
- Mid-level
- Analysis skills
Quick Apply
7d
Reserves Analyst
Handshake AI —Remote
- $85 an hour
- Part-time
- Remote
- Mid-level
- Analysis skills
- 2 years
Remote Site Manage
DFW Healthcare MSO LLC —Remote
- Full-time
- Remote
- Management
- Travel
- Senior level
Quick Apply
14d
Appeals Professional III (Weekend Work) (Part C)
TMF Health Quality Institute —Remote
- Weekends as needed
- Remote
- Writing skills
- Research
- Mid-level
- 401(k)
- Tuition reimbursement
Product Reviewer
G-MED NORTH AMERICA, Inc. —Remote
- Full-time
- Remote
- Mid-level
- 4 years
- Commuter assistance
- Paid parental leave
Quick Apply
Drilling Superintendent
Handshake AI —Remote
- $85 an hour
- Part-time
- Remote
- Research
- Mid-level
- 2 years
Outage Coordinator
Handshake AI —Remote
- $85 an hour
- Part-time
- Remote
- Oracle
- Research
- Mid-level
Pipeline Integrity Engineer
Handshake AI —Remote
- $85 an hour
- Part-time
- Remote
- Research
- Mid-level
- 2 years
Senior Scientist
Advocates for Human Potential, Inc. —Remote
- $105,000 - $120,000 a year
- Full-time
- Remote
- 5 years
- Children
- Travel
- Disability insurance
- Health insurance
Quick Apply
Process Safety Engineer
Handshake AI —Remote
- $85 an hour
- Part-time
- Remote
- Research
- Mid-level
- 2 years
Registered Dietician
UR Medicine Home Care —Webster, NY
- $67,700 - $89,294 a year
- Full-time
- Mid-level
- Bachelor's degree
- Home Health
Quick Apply
RN Facility Administrator
DAVITA —Jacksonville, IL
- $74,000 - $118,000 a year
- Full-time
- CPR Certification
- Nursing
- Microsoft Outlook
- Paid training
- Health insurance
PET/CT Technologist / Nuclear Medicine Technologist - 3048
Shared Medical Services —Wichita, KS
- Overnight shift
- Background check
- Pass drug screening
- Mid-level
- AD&D insurance
- Disability insurance
Psychiatrist
Step by Step Inc. —Allentown, PA
- $250 a day
- Contract
- Background check
- Doctoral degree
- Psychiatry
Quick Apply
Emergency Medicine Medical Director | Productivity Incentive Available!
Sound Physicians —Frederick, MD
- $225 - $240 a day
- Full-time
- BC/BE
- Patient care
- US work authorization
- Flexible schedule
13d
Willdan Energy new York management
lit light design —Brooklyn, NY
- $93,829.56 - $112,999.04 a year
- Contract
- Management
- Mid-level
- Contracts
- Flexible schedule
- Referral program
Quick Apply

I want to receive the latest job alert for qualifications

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

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

qualifications jobs

Utilization Management Physician Reviewer (Weekends)

Licensed Appeal Writer - Remote

Agent

Pharmacovigilance Agreements Contractor

Engineer - Degreed II

Reserves Analyst

Remote Site Manage

Appeals Professional III (Weekend Work) (Part C)

Product Reviewer

Drilling Superintendent

Outage Coordinator

Pipeline Integrity Engineer

Senior Scientist

Process Safety Engineer

Registered Dietician

RN Facility Administrator

PET/CT Technologist / Nuclear Medicine Technologist - 3048

Psychiatrist

Emergency Medicine Medical Director | Productivity Incentive Available!

Willdan Energy new York management

I want to receive the latest job alert for qualifications

Related Searches

Explore jobs in more locations

Job Seeker Tools

Employer Tools

Browse

Stay Connected