Must have NC or FL license or IMLCWe are seeking a Board-Certified Physician to support utilization management activities by reviewing clinical documentation and determining the medical appropriateness of inpatient, outpatient, and pharmacy services. This role plays a critical part in ensuring evidence-based, high-quality, and cost-effective care decisions.
The ideal candidate brings strong clinical judgment, experience within managed care, and the ability to apply nationally recognized medical guidelines in a fast-paced, collaborative environment.
Key Responsibilities
- Review and assess medical necessity for inpatient, outpatient, and pharmacy services
- Apply evidence-based guidelines and medical policy to utilization review determinations
- Provide peer-to-peer consultations when required
- Collaborate with care management and clinical teams to support appropriate care delivery
- Ensure compliance with regulatory, accreditation, and internal quality standards
- Accurately document decisions within established systems and turnaround times
Required Qualifications
- MD or DO with active Board Certification
- Active medical license in FL or NC, and/or participation in the Interstate Medical Licensure Compact (IMLC) or eligibility to apply
- Minimum 6 years of clinical practice experience
- At least 1 year of utilization review experience within a managed care or health plan environment
Preferred Qualifications
- Licensure in multiple states
- Board Certification in Cardiology, Radiation Oncology, or Neurology
- Experience with care management within the health insurance industry
- Willingness and ability to obtain additional state licenses as needed
Schedule & Call
- Hours: 8:00 AM 5:00 PM (local time zone)
- Call Rotation: 1 weekend every 16 weeks (only 3 times per year!)