Utilization Management Physician Reviewer

Dane Street

Physician providing utilization review services for the Group Health Department at Dane Street. Utilizing clinical expertise to review medical records and determine service appropriateness.

Posted 6/24/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

Review requests for Prior Authorizations and Appeals including medical records and make a medical necessity determination in compliance with state regulations, nationally recognized evidence-based guidelines, and client-specific policies.
Ensure clear, concise, and well-supported rationales for determinations.
Make mandated phone calls.
Provide responses in member friendly language using provided templates.
Return cases on or before the due date and time.
Assist with quality assurance of reports prior to submission to clients.
Maintain proper credentialing, state licenses, and any special certifications
Utilize current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature for decision-making.
Identify and respond to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits.
Provide copies of any criteria utilized in a review with the report.
Other duties & special projects, as assigned and based on business needs.

Requirements

What you’ll need

Board Certified M.D. or D.O. with current, unrestricted clinical license in any state in the US.
Minimum five years of postgraduate experience
Extensive clinical business background required
Experience in Utilization Management with criteria review utilizing standard practice guidelines
Medicaid/Medicare experience preferred
Working knowledge of URAC and relevant State and Federal compliance guidelines.
Excellent communication skills.
High-level understanding of medical insurance and utilization management.
Critical thinking
Ability to manage time efficiently and meet specific deadlines
Computer literacy and typing skills required

Benefits

Comp & perks

We offer generous Paid Time Off
an excellent benefits package
and a competitive salary

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical necessity determinationUtilization Managementcriteria reviewclinical business backgroundMedicaidMedicareURAC compliancestate compliance guidelinesfederal compliance guidelinesquality assurance

Soft Skills

communication skillscritical thinkingtime managementattention to detailproblem-solvinginterpersonal skillsorganizational skillsadaptabilityteam collaborationcustomer service

Certifications

Board Certified M.D.Board Certified D.O.current clinical license