Remote Role | Primary Care Physician / Internal Medicine – Utilization Management Role

Position Summary

A leading healthcare organization is seeking a Utilization Management Physician (UMP) for a full-time remote role. This position requires strong clinical judgment, critical thinking, and effective communication skills. The physician will be responsible for reviewing cases, determining medical necessity, and supporting evidence-based decision-making within a managed care environment.

Ideal Candidate Profile:
The ideal candidate would preferably be a Primary Care Physician. Alternatively, candidates who have completed a 3-year Internal Medicine residency followed by a 1–2 year specialty fellowship (such as Cardiology, Endocrinology, Rheumatology, Infectious Disease, or similar) will also be strongly considered.

Key Responsibilities

• Review pre-authorization requests, including initial and concurrent clinical reviews
• Evaluate post-service cases, including claims and appeals
• Render determinations based on clinical information and medical necessity using evidence-based guidelines and nationally recognized criteria (e.g., MCG, InterQual, CMS guidelines)
• Apply internal medical policies and member coverage guidelines to decision-making
• Review and update clinical criteria and decision-support tools annually
• Support provider education on treatment protocols and care pathways
• Provide guidance to utilization management staff on complex cases
• Conduct peer-to-peer discussions with treating providers as needed
• Ensure compliance with regulatory standards for authorization determinations
• Participate in discussions for urgent or escalated cases
• Clearly document rationale for non-certification decisions
• Collaborate with specialty physicians when additional expertise is required
• Participate in internal committees and clinical review initiatives as needed

Qualifications

• MD or DO from an accredited medical school
• Active, unrestricted medical license in at least one U.S. state
• Board certification in a primary specialty preferred
• 3–5 years of clinical experience required
• Minimum 3 years of Utilization Management experience
• Experience within managed care or health plan environments preferred
• Strong understanding of medical policy, clinical guidelines, and utilization review criteria
• Ability to analyze complex cases and make sound clinical decisions
• Willingness to participate in quality assurance and audit processes

Compensation & Benefits

• Competitive base salary
• Performance-based bonus opportunities
• 401(k) with employer participation
• Comprehensive health benefits for provider and eligible dependents
• Life and disability insurance
• Malpractice insurance coverage
• Paid time off
• CME allowance
• Reimbursement for licenses, fees, and professional dues
• Travel reimbursement (if applicable)
• Relocation assistance (if applicable)