Overview :

This role focuses on medical necessity reviews, clinical consultations, utilization management, quality improvement, and provider engagement. The physician will review complex cases and apply evidence-based clinical guidelines and applicable healthcare regulations to support appropriate patient care and utilization of services.

Key Responsibilities:

Serve as a clinical subject matter expert in General Medicine and Internal Medicine. Review complex authorization requests, appeals, and medical necessity determinations across inpatient, outpatient, post-acute, and specialty care settings. Conduct peer-to-peer consultations with treating physicians and other healthcare providers. Apply evidence-based clinical criteria and nationally recognized medical guidelines to clinical reviews. Provide clinical guidance to utilization management, care management, quality improvement, and operational teams. Review clinical documentation and support appropriate utilization of healthcare services. Interpret and apply applicable Medicaid regulations, medical policies, and healthcare quality standards. Participate in complex case reviews and multidisciplinary clinical discussions. Contribute to the development and maintenance of clinical policies, review guidelines, and utilization management strategies. Collaborate with providers and internal clinical teams to support quality outcomes and appropriate patient access to care.

Requirements:

MD or DO with an active, unrestricted U.S. medical license. Active, unrestricted California medical license required. Board Certified in Internal Medicine, Family Medicine, or a related primary care specialty. Minimum of 5 years of post-residency clinical experience in Internal Medicine, General Medicine, Hospital Medicine, Family Medicine, or a related clinical setting. Strong knowledge of evidence-based medicine and chronic disease management. Excellent clinical judgment, analytical, communication, and decision-making skills. Ability to work independently in a remote environment.

Preferred Experience:

Medicaid / Medi-Cal experience. Utilization management or utilization review. Prior authorization and medical necessity reviews. Appeals and quality review. Physician peer-to-peer reviews. Experience working with multidisciplinary clinical teams. Familiarity with nationally recognized clinical guidelines and healthcare quality standards.

Work Environment:

Fully remote / virtual role. Work must be performed while located within the United States. Regular interaction with physicians, healthcare providers, clinical teams, and other stakeholders. Strong ability to manage clinical reviews and work independently in a virtual environment.

Pay:

$100.00 - $120.00 per hour

Benefits:

401(k) Paid time off Retirement plan Vision insurance Application Question(s): Do you hold an MD or DO degree? Do you currently hold an active, unrestricted California medical license? Are you Board Certified in Internal Medicine, Family Medicine, or a related primary care specialty? Do you have at least 5 years of post-residency clinical experience?

Work Location:

In person