Utilization Management Physician Reviewer (TX Licensed)

Position 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.

Qualifications

• Advanced managed care industry expertise with C-Suite experience developing strategy, managing P&L, leading people, and ensuring contractual compliance.
• Ability to translate trends, innovation, operations, financing, costs, requirements and performance into scalable activities and repeatable outcomes.
• New product/ market strategy, design and implementation in the Commercial, Medicare, Medicare Advantage, Medicaid and/or associated lines of business.
• Operationalizing requirements for complex memberships, ensuring outcome delivery.
• Expert understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures including compliance and remediation activity.
• Ability to interpret and educate on complex concepts, requirements and legislation such as the Knox-Keene Act and HIPAA, State Department of Insurance requirements, Federal and State Health and Human Services requirements/ standards as well as CMS, NCQA, and URAC to ensure compliance with complex regulatory structures.
• Strategic leader with 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, and PowerPoint).
• Medical Degree (MD or DO) required; Must be actively licensed in Texas.
• Must have TX license in Pediatrics, Family or Internal Medicine.
• Masters degree in Healthcare or Business Administration or related field Degree preferred.
• 10+ years 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 with experience in multiple lines of business (Medicare, Medicaid, Healthcare Exchange, Commercial etc).
• 5+ years delivering results, managing teams and projects and mentoring other physicians in a health plan setting and/or consulting environment; driving complex, multi-faceted, multi-site, application/operational change/improvement programs and activities.