Physician Reviewer

Dane Street, LLC

18h • Remote

About The Position

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.

Requirements

• 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
• 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

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

Benefits

• medical, dental, and vision coverage for you and your family
• voluntary life insurance options for you, your spouse, and your children
• hospital indemnity, critical illness, accident indemnity, and pet insurance plans
• basic life insurance, short-term disability, and long-term disability coverage at no cost
• generous paid time off policy
• 401k plan with a company match
• Apple equipment and a media stipend are provided for remote workspace

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Ph.D. or professional degree
• Number of Employees: 101-250 employees