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Key Responsibilities:
- Conduct timely medical necessity reviews for inpatient admissions and post-acute services using MCG and InterQual guidelines.
- Lead peer-to-peer discussions with attending physicians to clarify clinical documentation and support appropriate care levels.
- Collaborate with utilization management and care management teams to ensure consistent, cost-effective care decisions.
Qualifications:
- Active, unrestricted M.D. or D.O. license in good standing; minimum 5 years clinical experience and 3 years in utilization management.
- Deep knowledge of Medicare Advantage requirements, CMS regulations, and MCG guidelines; InterQual familiarity preferred.
- Excellent physician-to-physician communication and negotiation skills; ability to work independently in a matrixed environment.
Benefits:
- Fully remote position within the United States with a Monday–Friday schedule aligned with Pacific Time.
- Opportunity to influence clinical quality, care coordination, and utilization outcomes in a Medicare Advantage setting.
- Professional environment emphasizing evidence-based decision-making, regulatory compliance, and patient-centered care.
Partner Company
Our partner company provides utilization management services for Medicare Advantage members, focusing on evidence-based clinical decision-making. It operates with a collaborative, matrixed team and emphasizes regulatory compliance and patient-centered care.