Job Title

Medical Director / Physician Reviewer, Utilization Management

Job Summary

The Medical Director / Physician Reviewer supports the medical management team by ensuring timely, consistent, and medically appropriate decisions for members and providers. This remote, hourly role reviews clinical cases, performs physician-to-physician outreach as needed, and applies medical policy to determine medical necessity for requested services. The position also handles grievance and appeal reviews within specialty scope and escalates complex or unclear cases to supervisory or Medical Director leadership when policy interpretation or additional review is required.

Key Responsibilities

• Complete timely clinical case reviews within board-certified specialty.

• Make physician-to-physician calls to obtain clinically relevant information for medical necessity decisions.

• Review requests for outpatient physical therapy, occupational therapy, and speech therapy services.

• Make medical necessity determinations for grievances and appeals within specialty scope.

• Apply medical policies consistently when evaluating cases.

• Identify cases requiring Medical Director review or policy interpretation and escalate appropriately.

• Support medical management staff in ensuring consistent, high-quality utilization review decisions.

• Use Microsoft Office Suite and other administrative tools to document and manage case activity.

• Work collaboratively with internal teams, providers, and leadership to support care decisions.

Required Qualifications

• MD or DO degree.

• Board certification from an approved certifying board, where applicable to job duties.

• Active, unrestricted medical license to practice medicine or health profession in the applicable jurisdiction.

• Experience with medical case review and utilization review preferred.

• Exposure to outpatient PT, OT, and ST review strongly preferred.

• Proficiency with Microsoft Office Suite.

Work Schedule

• Monday through Friday.

• 9:00 AM to 5:30 PM in your time zone.

• Remote.

• Hourly, non-exempt role with overtime eligibility.

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