Remote Medicare Advantage UM Physician Leader

SCAN Group; Long Beach (CA); Remote; USD 207,000 - 276,000; Full time

Benefits offered by this job

Remote work options

401(k) Retirement Plan

Impactful work in community health

Job summary

SCAN is seeking a Medicare Advantage Utilization Management (UM) Physician to provide physician-level medical necessity determinations for prior authorization, concurrent, and appeals programs. Local to California, with the role supporting timely, evidence-based decisions in a high-volume UM environment.

The ideal candidate will hold an MD/DO, be board-certified in Internal/Family/Emergency Medicine, and have 5+ years clinical practice plus 2–3 years UM experience.

Qualifications

• Graduate of an accredited medical school.
• Medical License (MD/DO) required.
• Active, unrestricted medical license; willingness to obtain additional state licensure as required.
• Board certification in Internal Medicine, Family Medicine, or Emergency Medicine.
• Minimum of 5 years of active clinical practice in relevant specialties.
• Minimum of 2-3 years of utilization management experience.
• Knowledge of MCG and UM regulatory frameworks (NCQA/URAC/CMS).
• Experience as Medical Director preferred.
• Strong communication and leadership skills.

Responsibilities

• Perform physician-level medical necessity review of prior authorization requests and concurrent reviews.
• Render determinations per Medicare guidelines and evidence-based criteria.
• Conduct peer-to-peer discussions with treating providers and document rationale.
• Serve as a reviewer for first-level appeals and escalate when needed.
• Mentor RN reviewers and intake staff; provide clinical guidance.
• Ensure UM decisions meet NCQA/URAC accreditation standards.

Skills

Analytical skills

Communication

Leadership

Regulatory knowledge

Education

Graduate of medical school

Board certification (Internal/Family/Emergency Medicine)

Tools

UM platforms

Electronic Health Records

Job description

SCAN is seeking a Medicare Advantage Utilization Management (UM) Physician to provide physician-level medical necessity determinations for prior authorization, concurrent, and appeals programs. Local to California, with the role supporting timely, evidence-based decisions in a high-volume UM environment.

The ideal candidate will hold an MD/DO, be board-certified in Internal/Family/Emergency Medicine, and have 5+ years clinical practice plus 2–3 years UM experience.