Licensed Physician Reviewer

You will provide physician-level oversight of utilization management activities while supporting clinical teams and maintaining strong coordination with health plan and local stakeholders.

• Serve as the primary physician reviewer for assigned Utilization Management cases.
• Provide delegated UM coverage across designated territories and assigned markets.
• Establish and review approximately 2–3 cases per day for each assigned market, with responsibility for up to six markets.
• Participate in health plan and local team calls to support timely case review and care coordination.
• Attend weekly Primary Care Provider (PCP) and Skilled Nursing Facility (SNF) meetings for assigned territories.
• Advise and support other physician reviewers on utilization management cases and clinical considerations.
• Collaborate with health plan teams and local clinical stakeholders to facilitate appropriate patient care.
• Contribute to process and quality improvement initiatives within the developing delegated UM function.
• Help identify opportunities to improve utilization management workflows, coordination, and outcomes.
• Take on additional responsibilities and assignments as directed by management.

Requirements:

The ideal candidate is a licensed physician with strong clinical judgment, communication skills, and the ability to collaborate effectively across health plans, clinical teams, and utilization management stakeholders.

• Active physician licensure appropriate to practice in the United States.
• Clinical experience that supports physician-level utilization management and medical case review.
• Strong clinical judgment and the ability to assess cases and make informed recommendations.
• Excellent verbal and written communication skills.
• Ability to communicate effectively with health plan representatives, local clinical teams, physician reviewers, and other stakeholders.
• Strong organizational skills and the ability to manage multiple cases and markets effectively.
• Ability to work independently while contributing effectively within a collaborative team environment.
• Comfortable participating in recurring clinical meetings, case discussions, and stakeholder calls.
• Strong commitment to patient-centered care and appropriate care coordination.
• Ability to contribute to process improvement and quality initiatives in an evolving healthcare environment.
• Professional judgment, accountability, and adaptability in a fast-paced clinical setting.

Benefits:

• Competitive compensation based on experience, education, geographic location, and other relevant factors.
• Potential eligibility for bonuses or commissions.
• Comprehensive employee benefits.
• Opportunities for career development and advancement.
• Virtual/remote work environment.
• Opportunity to contribute to innovative utilization management and care coordination practices.
• Collaborative environment focused on improving healthcare outcomes for seniors.
• Strong emphasis on work-life balance and professional growth.