Utilization Management Physician

The Provider Finder•Charleston, SC

11h•Remote

About The Position

We are seeking a Utilization Management Physician (UMP) for a full-time, remote opportunity with a well-established, multi-specialty healthcare organization in Florida. This role requires strong clinical judgment, critical thinking skills, and effective communication to support medical necessity determinations and utilization review processes.

Requirements

MD, DO, or PhD from an accredited medical school
Active, unrestricted Florida medical license
Board certification in primary specialty preferred
3–5 years of clinical experience
Experience with managed care and health plan benefits
Strong understanding of medical policy and application of clinical criteria
Ability to evaluate complex cases and make sound determinations

Responsibilities

Review pre-authorization requests, including initial and concurrent clinical review cases
Conduct post-service clinical reviews, including claims and appeals
Render determinations based on evidence-based medicine and nationally recognized criteria such as MCG, InterQual, and CMS guidelines
Ensure compliance with regulatory standards for pre-authorization determinations
Provide clear clinical rationale for non-certification decisions
Participate in peer-to-peer discussions (telephonic or electronic) regarding cases under review
Be available to address urgent cases with attending providers
Assist with provider education related to treatment protocols and options
Participate in committees as requested
Collaborate with specialty physicians as needed
Participate in quality review and interrater reliability processes