Utilization Review Physician

Overview

We are seeking a high-performing Physician Reviewer to join our Group Health division. The role is responsible for delivering timely, defensible utilization review determinations across a high-volume, fast-paced environment. Reviews span multiple case types, including preauthorization, appeals, DRG clinical validation, benefit review, and experimental/investigational determinations.

Key Responsibilities

• Perform utilization review for: Preauthorization requests, Appeals (first and second level), Independent external reviews, DRG validation and clinical review, Benefit and coverage determinations, Experimental/Investigational (E/I) review
• Apply evidence-based criteria and guidelines, including: InterQual, MCG, CMS guidelines (including 2-Midnight Rule), LCD/NCD, Client-specific policies
• Produce clear, concise, and defensible clinical rationales
• Maintain high accuracy and consistency across determinations
• Meet or exceed turnaround time (TAT) expectations, including urgent cases
• Participate in peer-to-peer discussions as needed
• Collaborate with QA and operational teams to ensure quality and compliance

Performance Metrics

• High daily review volume with strong accuracy
• Consistent adherence to client-specific requirements
• Able to manage short-TAT and urgent cases efficiently
• Clear, audit-ready documentation

Required Qualifications

• MD or DO, board-certified in Internal Medicine, Family Medicine, or similar
• Active, unrestricted medical license
• Prior utilization review experience, preferably in a health plan or IRO environment
• Familiarity with InterQual, MCG, and CMS guidelines
• Strong clinical judgment and documentation skills
• Ability to work independently in a high-throughput environment

Technical Skills

• Proficiency with standard business tools (e.g., Google Workspace, Microsoft Office)
• Comfortable working across multiple systems, including internal platforms and client-specific portals
• Strong navigation and documentation skills within web-based applications
• Able to manage multiple systems/screens simultaneously in a high-throughput environment
• Familiarity with Mac operating systems

Work Environment

• Remote work from home
• Full-time, Monday-Friday
• Occasional weekends and holiday coverage for urgent reviews

Benefits

• Medical, dental, and vision coverage for you and your family
• Voluntary life insurance options for you, your spouse, and your children
• Voluntary benefits including hospital indemnity, critical illness, accident indemnity, and pet insurance plans
• Basic life insurance, short-term disability, and long-term disability coverage at no cost
• Generous paid time off policy
• Apple equipment and a media stipend for remote workspace

About Dane Street

A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful forward-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers' Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.