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Utilization Review Physician

Medix™ • Contract • Remote (United States) • from $200 / hour • 3h ago

About the job

Job Posting: Medical Director – Utilization Management (Remote)

Position: Medical Director – Utilization Management
Pay: Up to $200 / hour
Employment Type: 1099 Contract
Hours: Full-Time, 40 hours/week
Location: Remote (Anywhere in the US)

Why Join Us?

Meaningful Payer-Side Impact: Work directly within a major national health plan, influencing decisions that impact member care quality, compliance, and operational strategy.
Stable Full-Time Hours: Enjoy a fully remote, 40-hour work week that offers the professional autonomy and structural balance many physicians look for when transitioning to payer-side roles.
Seamless Integration: Step into an established, well-oiled UM operation where your existing expertise is highly valued, featuring a streamlined 2-day training block to get you up to speed.

Key Responsibilities

As a Medical Director, you will provide clinical expertise and guidance on complex cases, ensuring high-quality, compliant review processes.

Utilization Management: Conduct reviews for medical necessity, appropriateness of care, and efficiency across commercial inpatient and outpatient services.
Case Escalation: Review escalated cases utilizing established medical policy criteria and guidelines (e.g., MCG, InterQual).
Provider Collaboration: Conduct peer-to-peer discussions with attending physicians and providers as needed.
Workflow Support: Support appeals, grievances, and prior authorization review workflows.
Production & Efficiency: Maintain a high-volume, efficient workflow, comfortably managing a production target of approximately 55+ cases per 8-hour day.
Compliance: Ensure strict compliance with NCQA, CMS, URAC, and all applicable state and federal regulatory standards.
Cross-Functional Teamwork: Collaborate with operational and clinical leadership teams.

Position Requirements

🚨 ABSOLUTE MUST-HAVE REQUIREMENT

Candidates must possess direct health plan/payer-side utilization management experience. Hospital-only case management or health system review experience will not be considered for this role.

Required Qualifications

Degree: MD or DO from an accredited institution.
Certification: Active Board Certification.
Licensure: Active, unrestricted medical license. Must hold a current license in at least one of the following states: New York (NY), Pennsylvania (PA), or West Virginia (WV).
Experience: Multiple years of dedicated payer-side/health insurance utilization management experience working specifically as a Medical Director or Physician Reviewer.
Systems: Experience working within managed care workflows, utilizing production queues, EMR platforms (Epic preferred), and strict turnaround time (TAT) metrics.
Work Style: Ability to work completely independently and productively in a fast-paced, remote production environment.

Preferred Experience

Experience supporting Medicare Advantage and/or Commercial lines of business.
Multi-state medical licensure.
Prior experience heavily focused on prior authorizations, appeals, and grievances.