Utilization Management Physician Reviewer

CommonSpirit Health•Bakersfield, CA

1d•Remote

About The Position

As the Utilization Management (UM) Physician Reviewer, you will report to the Medical Director of UM and provide clinical expertise to ensure high-quality, medically necessary, and efficient patient care aligned with regulatory requirements. This role involves making direct decisions in prior authorization, concurrent review of hospitalized patients, and discharge planning. Key responsibilities include clinical review of prior authorization, concurrent review, and retrospective review requests using critical thinking and established guidelines, interpreting benefit language, and accurate documentation. The reviewer will engage in peer-to-peer discussions with providers, collaborate with other healthcare professionals, and handle appeals and grievances. Ensuring compliance with federal, state, and accreditation standards is crucial. The position also involves acting as a clinical liaison, participating in case reviews and fair hearing processes, identifying utilization trends, and contributing to policy development and quality improvement. The UM Physician Reviewer will guide UM nurses and clinical staff and stay current with evidence-based medical literature and healthcare trends. This position is remote, but will be expected to work PST business hours. This position is part-time, working approximately 20 hours/week, with flexible days/hours. The schedule includes weekend and holiday rotations ensuring coverage for urgent reviews.

Requirements

Clear and current California MD or DO license.
Proficiency in using electronic health records and UM software platforms (after training).

Nice To Haves

2+ years of experience in a direct patient care setting, Primary care specialty preferred.
Experience in utilization management, medical review, or managed care setting preferred.
Strong knowledge of clinical standards of care, NCQA requirements, CMS guidelines, and Medicaid / Medicare programs and dual eligible populations, and benefit systems preferred.

Responsibilities

Provide clinical expertise to ensure high-quality, medically necessary, and efficient patient care aligned with regulatory requirements.
Make direct decisions in prior authorization, concurrent review of hospitalized patients, and discharge planning.
Clinical review of prior authorization, concurrent review, and retrospective review requests using critical thinking and established guidelines
Interpreting benefit language, and accurate documentation.
Engage in peer-to-peer discussions with providers
Collaborate with other healthcare professionals
Handle appeals and grievances.
Ensuring compliance with federal, state, and accreditation standards
Act as a clinical liaison
Participate in case reviews and fair hearing processes
Identify utilization trends
Contribute to policy development and quality improvement.
Guide UM nurses and clinical staff
Stay current with evidence-based medical literature and healthcare trends.