Utilization Management Physician Reviewer (PA Licensed)

About the Role

Clearlink Partners is seeking a seasoned healthcare professional to join our team as a key contributor in managed care consultancy. This role involves providing strategic direction, clinical review, and operational oversight for health plan markets and products, with a focus on medical management and health service performance.

Responsibilities

• Conduct clinical review of prior authorization, concurrent review, and retrospective review requests to determine medical necessity and appropriateness of services.
• Collaborate with utilization management nurses and clinical staff to support timely decision-making.
• Review appeals and grievances related to medical necessity and participate in fair hearing processes as required.
• Ensure compliance with federal and state regulations, NCQA/URAC standards, and MCO policies.
• Serve as a liaison between the medical management department and providers, offering guidance on clinical criteria and utilization trends.
• Participate in interdisciplinary rounds and case review meetings as needed.
• Identify utilization trends and contribute to the development of policies, clinical criteria, and medical management strategies.
• Support quality improvement initiatives and population health programs as needed.
• Provide strategic direction for health plan market/product medical management and health service operational oversight, management, and performance.
• Lead engagements, ensuring completion of all contracted services, and present findings, recommendations, and plans to client executives.
• Facilitate problem-solving discussions and advise key decision-makers.
• Develop strategies, goals, and plans in response to changing business conditions.
• Establish short-term KPIs and long-term goals, tracking progress to ensure achievement.
• Coach and mentor staff to reach established engagement goals and plan deliverables.

Qualifications

• Advanced managed care industry expertise with C-Suite experience in strategy development, P&L management, leadership, and contractual compliance.
• Ability to translate trends, innovation, operations, financing, costs, requirements, and performance into scalable activities and repeatable outcomes.
• Experience in new product/market strategy, design, and implementation across various lines of business (Commercial, Medicare, Medicare Advantage, Medicaid).
• Expertise in operationalizing requirements for complex memberships and ensuring outcome delivery.
• Deep understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures, including compliance and remediation.
• Ability to interpret and educate on complex concepts, requirements, and legislation such as the Knox-Keene Act, HIPAA, State Department of Insurance requirements, and CMS, NCQA, and URAC standards.
• Strategic leadership skills with the ability to produce, manage, and maintain system-wide change through influence and persuasion.
• Advanced knowledge of project management principles, methods, and techniques.
• Excellent communication skills, both written and oral.
• High proficiency with core office software (Excel, Word, PowerPoint); Visio skills preferred.

Experience

• Medical Degree (MD or DO) required; must be actively licensed in Pennsylvania.
• Master’s degree in Healthcare or Business Administration or related field preferred.
• 10+ years of administrative leadership achievement in health plan operations with progressive responsibility; CMO level experience preferred.
• 7+ years of experience in a government payor environment with expertise in medical management practice across multiple lines of business.
• 5+ years of experience managing teams, projects, and mentoring physicians in a health plan setting and/or consulting environment, driving complex change programs.

Physical Requirements

• Ability to sit for extended periods.
• Ability to speak, hear, and distinguish speech and sounds.
• Dexterity to use a computer and electronic devices.
• Clear vision to assess data and information.
• Fluent communication in English, both verbal and written.
• Ability to manage stressful situations and balance multiple duties.

Additional Information

Expected Hours of Work: Friday 8am – 5pm, with flexibility to adjust to client schedules.
Travel: May be required as needed by the client.
Direct Reports: None.
Time Zone: Eastern or Central.
Salary Range: $100.00 - $150.00/hr.