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