Physician Specialist - Utilization Review

Cencora | Pharma solutions; Jalisco; A distancia; USD 180,000 - 250,000; Jornada completa

Descripción de la vacante

A U.S.-based healthcare consulting firm is looking for a Physician Specialist in Utilization Review to improve documentation accuracy and reimbursement outcomes. This role focuses on collaborating with medical teams and ensuring compliance with utilization management guidelines while participating in ongoing training and professional development opportunities.

Servicios

Competitive salary package

Annual performance-based bonus

Comprehensive training

Ongoing professional development

Opportunity to work remotely

Formación

• Minimum 2 years of clinical experience in acute care settings.
• Familiarity with ICD-10 and utilization review.
• Strong English communication skills.

Responsabilidades

• Conduct medical necessity reviews for hospital admissions and services.
• Collaborate with physicians to ensure appropriate justification of care.
• Support appeals and denial resolutions with third-party payers.

Conocimientos

Attention to detail

Professional ethics

Communication

Educación

Medical degree (MD or equivalent)

Herramientas

EHR systems

Payer portals

Documentation systems

Descripción del empleo

About the Role

A confidential U.S.-based healthcare consulting firm is seeking a highly qualified Physician Specialist – Utilization Review to join its clinical operations team. This organization partners with hospitals and medical groups across the U.S. to improve documentation accuracy, reimbursement outcomes, and healthcare quality through expert services in utilization management, clinical documentation integrity, and revenue cycle strategy.

As a key member of the utilization review team, you will be responsible for evaluating medical necessity for inpatient admissions and ongoing care, supporting appeals and denials, and collaborating closely with physicians, case managers, and health plans to ensure proper documentation and compliance.

Key Responsibilities

• Conduct prospective, concurrent, and retrospective medical necessity reviews for hospital admissions and services.
• Collaborate with attending physicians to clarify clinical documentation and ensure appropriate justification of patient care.
• Support appeals and denial resolution processes by documenting justification and communicating with third-party payers.
• Act as a liaison between the medical team and payers, ensuring compliance with utilization management guidelines.
• Participate in peer review and utilization review meetings and contribute to continuous improvement efforts.
• Communicate effectively with clinical and non-clinical stakeholders to resolve authorization and reimbursement issues.

Minimum Qualifications

• Medical degree (MD or equivalent) required.
• Minimum of 2 years of clinical experience in acute care hospital settings.
• Familiarity with ICD-10 and utilization review principles.
• Strong English communication skills (written and spoken).
• Proficient in working with EHRs, payer portals, and documentation systems.
• High attention to detail, integrity, and professional ethics.

What’s Offered

• Competitive salary package.
• Annual performance-based bonus.
• Comprehensive training and ongoing professional development.
• Opportunity to work remotely in a mission-driven, quality-focused environment.