Remote Utilization Review Physician

About the role

This remote position is with a technology‑driven health insurance organization that focuses on member‑centered care. The physician will evaluate the medical appropriateness of inpatient, outpatient, and pharmacy services using clinical information and evidence‑based guidelines.

Key responsibilities

• Conduct timely medical reviews in line with quality standards and turnaround times.
• Make clinical determinations using evidence‑based criteria, internal guidelines, and sound clinical judgment.
• Document decisions clearly in workflow systems using approved templates.
• Participate in peer‑to‑peer discussions with treating providers to clarify information and explain review outcomes.
• Review escalated cases as needed and ensure compliance with applicable laws and regulations.
• Maintain accurate, member‑friendly documentation.

Required profile

• Board‑certified MD or DO.
• Licensed in Florida or North Carolina, or eligible for/active participation in the Interstate Medical Licensure Compact (IMLC).
• Minimum six (6) years of clinical practice experience.
• At least one (1) year of utilization review experience in a managed‑care or health‑insurance setting.

Required skills

• Proficiency in applying evidence‑based clinical guidelines.
• Ability to use electronic workflow and documentation systems.