100 % Remote Utilization Management Role | Primary Care Physician / Internal Medicine Physicians Preferred

The Provider Finder•Charleston, SC

2d•Remote

About The Position

A leading healthcare organization is seeking a Utilization Management Physician (UMP) for a full-time remote role. This position requires strong clinical judgment, critical thinking, and effective communication skills. The physician will be responsible for reviewing cases, determining medical necessity, and supporting evidence-based decision-making within a managed care environment. The ideal candidate would preferably be a Primary Care Physician. Alternatively, candidates who have completed a 3-year Internal Medicine residency followed by a 1–2 year specialty fellowship (such as Cardiology, Endocrinology, Rheumatology, Infectious Disease, or similar) will also be strongly considered.

Requirements

MD or DO from an accredited medical school
Active, unrestricted medical license in at least one U.S. state
3–5 years of clinical experience required
Minimum 3 years of Utilization Management experience
Strong understanding of medical policy, clinical guidelines, and utilization review criteria
Ability to analyze complex cases and make sound clinical decisions
Willingness to participate in quality assurance and audit processes

Nice To Haves

Board certification in a primary specialty preferred
Experience within managed care or health plan environments preferred
Preferably a Primary Care Physician
Alternatively, candidates who have completed a 3-year Internal Medicine residency followed by a 1–2 year specialty fellowship (such as Cardiology, Endocrinology, Rheumatology, Infectious Disease, or similar)

Responsibilities

Review pre-authorization requests, including initial and concurrent clinical reviews
Evaluate post-service cases, including claims and appeals
Render determinations based on clinical information and medical necessity using evidence-based guidelines and nationally recognized criteria (e.g., MCG, InterQual, CMS guidelines)
Apply internal medical policies and member coverage guidelines to decision-making
Review and update clinical criteria and decision-support tools annually
Support provider education on treatment protocols and care pathways
Provide guidance to utilization management staff on complex cases
Conduct peer-to-peer discussions with treating providers as needed
Ensure compliance with regulatory standards for authorization determinations
Participate in discussions for urgent or escalated cases
Clearly document rationale for non-certification decisions
Collaborate with specialty physicians when additional expertise is required
Participate in internal committees and clinical review initiatives as needed