Physician Reviewer

Overview

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.

Key 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

Performance Metrics

• High daily review volume with strong accuracy
• Consistent adherence to client-specific requirements
• Ability to manage short-TAT and urgent cases efficiently
• Clear, audit-ready documentation

Required Qualifications

• 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

Technical Skills

• 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

Work Environment

• Remote work from home
• Full-time, Monday–Friday
• Availability for occasional weekends and holiday coverage for urgent reviews