Top 43610 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
Care Manager, Concurrent Review (Remote)
EmblemHealth —New York, NY
- $68,040 - $118,800 a year
- Remote
- Nursing
- Microsoft Outlook
- RN License
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
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
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CHS Utilization and Appeals Manager
Catholic Health —Melville, NY
- $110,000 - $150,000 a year
- Nursing
- RN License
- Word processing
- Health insurance
- Tuition reimbursement
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
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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
Behavioral Health Utilization Manager (temporary)
WellSense Health Plan —Remote
- $33.41 - $48.56 an hour
- Temporary
- LMFT
- Nursing
- Microsoft Excel
Design Engineering Manager
Nifco America, Corp. —Canal Winchester, OH
- Full-time
- Background check
- Clean driving record
- 5 years
- Health savings account
- Relocation assistance
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Branch Clinical Manager (RN) Home Health
Adaptive Home Health —Detroit, MI
- Full-time
- RN License
- Home Health
- Senior level
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HOME CARE - RN CASE MANAGER
Aultman Health Foundation —Canton, OH
- Weekends as needed
- Nursing
- RN License
- Computer literacy
AVP I, IT Services & Facilities
Armed Forces Insurance —Leavenworth, KS
- $106,000 - $124,000 a year
- Microsoft Excel
- Microsoft Outlook
- Bachelor of Science
- Paid holidays
- Disability insurance
Physician Opportunities
Summit Medical Consultants LLC —Colorado Springs, CO
- $300,000 - $350,000 a year
- Weekends as needed
- Medicine
- Skilled nursing facility
- Nursing home
- Health savings account
- Relocation assistance
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Histology Manager
Medipath, LLC —Miramar, FL
- From $120,000 a year
- Full-time
- Spanish
- Word processing
- English
- Health savings account
- Relocation assistance
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Nurse Educator (RN)
Wake Robin Corporation —Shelburne, VT
- $36.70 - $44.77 an hour
- Weekends as needed
- Nursing
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- Mid-level
- 403(b) matching
- Disability insurance
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Respiratory Therapy Manager
Froedtert South, Inc. —Pleasant Prairie, WI
- Full-time
- Acute care
- PALS Certification
- Hospital
- Opportunities for advancement
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7d
International Franchise seeks Print Production Specialist
Minuteman Press International —San Fernando Valley, CA
- $55,000 - $60,000 a year
- Full-time
- Sales
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- Mid-level
- Paid holidays
- Health insurance
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Regional Clinical Manager
VITRA Health —Boston, MA
- $130,000 - $140,000 a year
- Full-time
- Nursing
- RN License
- Customer service
- Disability insurance
- Health insurance
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Assistant Rehab Manager
Promise Care NJ —East Orange, NJ
- $100,000 - $112,000 a year
- Full-time
- Mid-level
- 3 years
- Driver's License
- Continuing education credits
- Health savings account
Quick Apply
Mine Engineer - USA
Magris Talc —Cameron, MT
- $85,000 - $95,000 a year
- Full-time
- Inventory management
- Mid-level
- Analysis skills
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
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)

Care Manager, Concurrent Review (Remote)

Denials & Appeals Administrator (RN)

Utilization Review Nurse

CHS Utilization and Appeals Manager

Claims, Appeal, UR Case Management Coordinator

Utilization Review Specialist

Behavioral Health Utilization Manager (temporary)

Design Engineering Manager

Branch Clinical Manager (RN) Home Health

HOME CARE - RN CASE MANAGER

AVP I, IT Services & Facilities

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Histology Manager

Nurse Educator (RN)

Respiratory Therapy Manager

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Regional Clinical Manager

Assistant Rehab Manager

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