Top 50109 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
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
Utilization Management- RN
South Country Health Alliance —Medford, MN
- $34.39 - $47.94 an hour
- Weekends as needed
- Nursing
- Microsoft Excel
- Microsoft Outlook
- Disability insurance
- Health insurance
13d
Utilization Review Supervisor - FT - Day - Utilization Resource Management Pennington NJ
Capital Health —Pennington, NJ
- $86,964.80 - $113,672.00 a year
- 8 hour shift
- Nursing
- RN License
- Computer literacy
- AD&D insurance
- Disability insurance
Manager of Case Management
UnitedHealth Group —Las Vegas, NV
- $91,700 - $163,700 a year
- Full-time
- Nursing
- RN License
- Hospital
Utilization Review Manager
Assurance Health System, LLC —Remote
- Full-time
- Remote
- Management
- Psychiatry
- RN License
- Health insurance
- 401(k)
Quick Apply
1d
Program Manager EHR Trainer
SCA Health —Remote
- $112,000 - $125,000 a year
- Full-time
- 3 years
- Continuous improvement
- Mentoring
- Disability insurance
- Health insurance
12d
Utilization Review Nurse
Cobalt Benefits Group LLC —Orlando, FL
- $90,000 - $98,000 a year
- Full-time
- Remote
- Nursing
- Microsoft Excel
- Microsoft Outlook
- Health savings account
- AD&D insurance
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
Nurse Case Manager, Utilization Management
1199SEIU Family of Funds —New York, NY
- $89,400 - $106,100 a year
- Full-time
- Nursing
- RN License
- Mid-level
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
Enablement Manager, MedSpa
Sunbit —Remote
- $110,000 - $120,000 a year
- Email
- Mid-level
- Continuous improvement
- Travel
- Health savings account
- Health insurance
Quick Apply
8d
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
Care Manager, Concurrent Review (Remote)
EmblemHealth —New York, NY
- $68,040 - $118,800 a year
- Remote
- Nursing
- Microsoft Outlook
- RN License
Mgr Denials Management
Brown University Health —Providence, RI
- $97,718.40 - $195,436.80 a year
- 8 hour shift
- Remote
- RN License
- 5 years
- Writing skills
Claims, Appeal, UR Case Management Coordinator
90 Degree Benefits —Remote
- Part-time
- Remote
- English
- Mid-level
- High school diploma or GED
- 401(k)
- Work from home
Quick Apply
Behavioral Health Utilization Manager (temporary)
WellSense Health Plan —Remote
- $33.41 - $48.56 an hour
- Temporary
- LMFT
- Nursing
- Microsoft Excel
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

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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)

Clinical Operations Manager

Utilization Management- RN

Utilization Review Supervisor - FT - Day - Utilization Resource Management Pennington NJ

Manager of Case Management

Utilization Review Manager

Program Manager EHR Trainer

Utilization Review Nurse

Senior Manager, Utilization Management

Nurse Case Manager, Utilization Management

RN Case Manager - Complex Cases

Care Manager - Utilization Management (Must Have UAS Experience)

Case Manager

Enablement Manager, MedSpa

Denials & Appeals Administrator (RN)

Care Manager, Concurrent Review (Remote)

Mgr Denials Management

Claims, Appeal, UR Case Management Coordinator

Behavioral Health Utilization Manager (temporary)

Clinical Manager, Global

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