Top 50043 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
Director - Pharmacy Network Contracting & Public Payer Relations
Hemophilia Alliance —Remote
- $130,000 - $170,000 a year
- Full-time
- Background check
- Up to 50% travel
- 5 years
- Health savings account
- Health insurance
Quick Apply
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 Vice President - Operations
Confidential —Broward County, FL
- From $180,000 a year
- Full-time
- Background check
- Master's degree
- Bachelor's degree
- Health savings account
- Health insurance
Quick Apply
4d
Fleet Coordinator
Ontrak Logistics —Norfolk, VA
- Full-time
- Hybrid work
- Mid-level
- Organizational skills
- Communication skills
Quick Apply
4d
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
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
Utilization Review Manager
Assurance Health System, LLC —Remote
- Full-time
- Remote
- Management
- Psychiatry
- RN License
- Health insurance
- 401(k)
Quick Apply
16h
Care Manager, Concurrent Review (Remote)
EmblemHealth —New York, NY
- $68,040 - $118,800 a year
- Remote
- Nursing
- Microsoft Outlook
- 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
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, Per Diem (SMH)
UCLA Health —Santa Monica, CA
- $93.83 - $98.52 an hour
- Per diem
- Nursing
- RN License
- BLS Certification
Nurse Director Utilization Review and Case Management
Clinical Management Consultants —Berkeley, CA
- $152,580 - $175,960 a year
- Full-time
- Acute care
- Hospital
- Acute care experience
- Health insurance
- Dental insurance
Case Management RN Manager
Clinical Management Consultants —Grand Junction, CO
- $123,670 - $162,960 a year
- Full-time
- Nursing
- Senior level
11d
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
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
Enablement Manager, MedSpa
Sunbit —Remote
- $110,000 - $120,000 a year
- Email
- Mid-level
- Continuous improvement
- Travel
- Health savings account
- Health insurance
Quick Apply
7d
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
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

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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)

Director - Pharmacy Network Contracting & Public Payer Relations

Clinical Operations Manager

Senior Vice President - Operations

Fleet Coordinator

Program Manager EHR Trainer

Utilization Review Nurse

Utilization Review Manager

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RN Case Manager

Field RN Case Manager

Nurse Case Manager, Utilization Management

RN Case Manager, Per Diem (SMH)

Nurse Director Utilization Review and Case Management

Case Management RN Manager

Utilization Management Clinician I

Case Manager

Enablement Manager, MedSpa

Care Manager - Utilization Management (Must Have UAS Experience)

Denials & Appeals Administrator (RN)

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