Remote Physician Reviewer-Utilization Management (MD/DO)-249027

Physician Reviewer – Utilization Management (Remote)-Full TimeOverviewWe are seeking a Board-Certified Physician (Internal Medicine or Similar background preferred with Active FL or NC License and/or IMLC) to support utilization management activities by reviewing clinical documentation and determining the medical appropriateness of inpatient, outpatient, and pharmacy services. This role plays a critical part in ensuring evidence-based, high-quality, and cost-effective care decisions.The ideal candidate brings strong clinical judgment, experience within managed care, and the ability to apply nationally recognized medical guidelines in a fast-paced, collaborative environment.Key ResponsibilitiesReview and assess medical necessity for inpatient, outpatient, and pharmacy servicesApply evidence-based guidelines and medical policy to utilization review determinationsProvide peer-to-peer consultations when requiredCollaborate with care management and clinical teams to support appropriate care deliveryEnsure compliance with regulatory, accreditation, and internal quality standardsAccurately document decisions within established systems and turnaround timesRequired QualificationsMD or DO with active Board CertificationActive medical license in FL or NC, and/or participation in the Interstate Medical Licensure Compact (IMLC) or eligibility to applyMinimum 6 years of clinical practice experienceAt least 1 year of utilization review experience within a managed care or health plan environmentPreferred QualificationsLicensure in multiple statesBoard Certification in Internal Medicine or similar fieldExperience with care management within the health insurance industryWillingness and ability to obtain additional state licenses as neededSchedule & CallHours: 8:00 AM – 5:00 PM (local time zone)Call Rotation: 1 weekend every 16 weeks