Overview
We are seeking a high-performing Physician Reviewer to join our Group Health division. The role is responsible for delivering timely, defensible utilization review determinations across a high-volume, fast-paced environment. Reviews span multiple case types, including preauthorization, appeals, DRG clinical validation, benefit review, and experimental/investigational determinations.
Key Responsibilities
- Perform utilization review for:
- Preauthorization requests
- Appeals (first and second level)
- Independent external reviews
- DRG validation and clinical review
- Benefit and coverage determinations
- Experimental/Investigational (E/I) review
- Apply evidence-based criteria and guidelines, including:
- InterQual
- MCG
- CMS guidelines (including 2-Midnight Rule)
- LCD/NCD
- Client-specific policies
- Produce clear, concise, and defensible clinical rationales
- Maintain high accuracy and consistency across determinations
- Meet or exceed turnaround time (TAT) expectations, including urgent cases
- Participate in peer-to-peer discussions as needed
- Collaborate with QA and operational teams to ensure quality and compliance
- Reviews may be conducted within internal systems or client-specific platforms, depending on assignment and client requirements
Performance Metrics
- High daily review volume with strong accuracy
- Consistent adherence to client-specific requirements
- Ability to manage short-TAT and urgent cases efficiently
- Clear, audit-ready documentation
Required Qualifications
- MD or DO, board-certified in Internal Medicine, Family Medicine, or similar
- Active, unrestricted medical license
- Prior utilization review experience, preferably in a health plan or IRO environment
- Familiarity with InterQual, MCG, and CMS guidelines
- Strong clinical judgment and documentation skills
- Ability to work independently in a high-throughput environment
Technical Skills
- Proficiency with standard business tools (e.g., Google Workspace, Microsoft Office)
- Comfortable working across multiple systems, including internal platforms and client-specific portals
- Strong navigation and documentation skills within web-based applications
- Ability to manage multiple systems/screens simultaneously in a high-throughput environment
- Familiarity with Mac operating systems
Work Environment
- Remote work from home
- Full-time, Monday–Friday
- Availability for occasional weekends and holiday coverage for urgent reviews