Remote Physician Reviewer - Utilization Management

Physician Reviewer – Utilization Management (Remote)

Location:

100% Remote (Must reside in an eligible U.S. state; must be Licensed in FL or NC and/or active Interstate Medical Licensure Compact (IMLCC) or eligible to apply for IMLCC.)

Schedule:

Monday – Friday | 8:00 AM – 5:00 PM (Local Time Zone)

On-call rotation: 1 weekend every 16 weeks

Compensation:

$211,200 – $275,000 / year (Commensurate with experience and qualifications)

Position Summary

We are seeking a board-certified physician to join a collaborative clinical operations team as a Physician Reviewer in Utilization Management. In this role, you will evaluate inpatient, outpatient, and pharmacy service requests for medical necessity, ensuring patients receive timely, high-quality, and evidence-based care while maintaining strict clinical and regulatory standards.

Key Responsibilities

• Clinical Coverage Determinations: Conduct comprehensive, timely medical reviews and render coverage determinations on initial requests, escalations, and appeals using evidence-based guidelines and clinical acumen.
• Provider Peer-to-Peer Discussions: Lead professional, collaborative peer-to-peer discussions with treating providers to discuss clinical rationales, clarify treatment details, and suggest evidence-based alternatives when applicable.
• Clear Documentation: Document all clinical determinations and decision rationales accurately in review templates, ensuring communications are clear, defensible, and accessible to members and clinical teams alike.
• Quality & Turnaround Compliance: Consistently meet established quality standards and regulatory turnaround times for all assigned clinical reviews.
• Continuous Improvement: Collaborate with the medical director and interdisciplinary teams to ensure adherence to compliance laws, regulations, and clinical criteria updates.

Required Qualifications

• Education & Credentials: Medical Degree (MD or DO) with active Board Certification.
• Licensure:
• Active, unrestricted medical license in Florida or North Carolina
• Active Interstate Medical Licensure Compact (IMLCC) qualification / immediate eligibility to apply.
• Clinical Experience: Minimum of 6+ years of direct patient care / clinical practice.
• Managed Care Experience: Minimum of 1+ years of utilization review experience within a managed care organization (MCO), health plan, or health insurance setting.
• Workspace & Technical: Secure, private, HIPAA-compliant home office with high-speed internet.

Preferred Qualifications

• Board Certification in Cardiology, Medical/Radiation Oncology, or Neurology.
• Active medical licenses in multiple states (or willingness to obtain additional state licensure with employer sponsorship).
• Prior background in care management or health plan quality review.

Location Requirements

• This position is open to remote candidates across most of the continental United States MUST be licensed in FL or NC and/or active Interstate Medical Licensure Compact (IMLCC) or eligible to apply for IMLCC.

Benefits & Perks

• Comprehensive health coverage (Medical, Dental, and Vision)
• 401(k) retirement savings plan
• Generous paid time off / vacation policy, plus paid company holidays and sick leave
• Life and disability insurance
• Employer-sponsored license renewals and multi-state credentialing support