Medicare Advantage Utilization Management Physician (Agency Temp, Part-time)
Core
Physician-level decision-making for prior authorization, concurrent review, and appeals in Medicare Advantage plans, serving as clinical authority for medical necessity determinations.
Role type
Senior Utilization Management Physician (Medicare Advantage)
Builds
Timely, clinically sound, and cost-effective utilization management determinations for a nonprofit health organization.
Domain
Healthcare / Medicare Advantage / Utilization Management
Required skills
Medical necessity review, peer-to-peer discussions, regulatory compliance (CMS/NCQA/URAC), Medicare guidelines, clinical judgment, mentorship, provider relations
Preferred skills
Medical Director experience, appeals/grievances expertise, population health, value-based care, advanced analytics
Technologies
UM workflow platforms, Electronic Health Records (EHR), productivity software
Responsibilities
Perform physician-level medical necessity reviews for prior authorization and concurrent reviews; conduct peer-to-peer discussions with treating providers; serve as reviewer for first-level appeals; provide clinical guidance to RN reviewers; ensure compliance with accreditation standards; communicate determinations to network providers.
Seniority
Senior, hands-on IC
