Medical Director Associate
Remote
Physician Reviewer – Post-Acute Care (Utilization Management)
The Physician Reviewer supports the Medical Management team by ensuring timely, consistent, and clinically sound medical-necessity determinations for members and providers, with a primary focus on post-acute care services. This role is responsible for conducting clinical case reviews, engaging in peer-to-peer (P2P) discussions with treating providers, and applying evidence-based medical policies and guidelines to support appropriate utilization and high-quality care.
Key Responsibilities
Perform timely and accurate clinical case reviews for post-acute care services, including skilled nursing facilities (SNF), inpatient rehabilitation (IRF), long-term acute care (LTACH), and home health.
Conduct physician-to-physician (P2P) discussions to obtain additional clinical information and communicate medical-necessity determinations.
Apply established clinical criteria, guidelines (e.g., MCG), and company medical policies to ensure consistent and defensible decision-making.
Document all determinations, clinical rationale, and outreach efforts clearly and in accordance with organizational and regulatory standards.
Collaborate with utilization management nurses and interdisciplinary teams to ensure efficient case processing and consistent outcomes.
Support clinical appeals, reconsiderations, and quality initiatives as needed.
Provide clinical guidance to internal teams and contribute to maintaining the integrity of medical management programs.
Serve as a resource for interpretation of medical policies and participate in internal and external clinical discussions or committees as appropriate.
Required Qualifications
MD or DO degree with active, unrestricted U.S. medical license.
Board certification by ABMS or AOA (as applicable to specialty).
Minimum of 3 years of clinical experience in inpatient or post-acute care settings.
At least 1 year of experience conducting medical-necessity reviews in a utilization management or similar setting.
Demonstrated ability to apply clinical criteria and guidelines in decision-making.
Strong communication skills with the ability to effectively engage providers during P2P discussions.
Excellent documentation skills and ability to meet turnaround time requirements.
Preferred Qualifications
Experience in utilization management, managed care, or health plan medical management.
Familiarity with post-acute care transitions and levels of care.
Experience using clinical decision support tools such as MCG or InterQual.
Prior involvement in appeals, quality improvement initiatives, or medical policy development.
Work Schedule
Full-time, Monday through Friday, within the hours of 8:00 AM – 8:00 PM CST.
Optional weekend coverage based on business needs.
Candidates must reside within the United States and within 50 miles of a designated PulsePoint location.
Compliance and Work Standards
Maintain compliance with HIPAA and all applicable regulatory and company policies.
Meet established productivity, quality, and turnaround-time standards.
Participate in on-call rotations or after-hours coverage as required.
Additional Information
This role operates under the guidance of a Medical Director and supports clinical program integrity across utilization management functions. The Physician Reviewer may assist in appeals, credentialing support, medical policy interpretation, and quality improvement efforts. This position requires strong analytical, communication, and problem-solving skills consistent with URAC-accredited standards.