Remote Physician Reviewer - 249027

Medix™; United States; On-site; USD 180,000 - 220,000; Full time

Job summary

A technology-driven health insurance organization is seeking a board-certified MD or DO for a medical review role. The candidate will evaluate the appropriateness of inpatient and outpatient services, ensuring compliance with established standards. Preferred qualifications include licensure in multiple states and experience in the health insurance industry. Responsibilities involve conducting timely reviews, making evidence-based decisions, and participating in peer discussions. This role requires minimum 6 years clinical experience and at least 1 year in utilization review.

Qualifications

• Minimum of 6 years of clinical practice experience.
• At least 1 year of utilization review experience.
• Licensed or eligible for licensure in multiple states.

Responsibilities

• Conduct timely medical reviews in alignment with established quality standards.
• Make clinical determinations using evidence-based criteria.
• Document decisions accurately in workflow systems.
• Participate in peer-to-peer discussions with treating providers.
• Maintain compliance with applicable laws and regulations.

Skills

Clinical judgment

Evidence-based decision-making

Documentation skills

Compliance with laws and regulations

Education

Board-certified MD or DO

Licensed in Florida or North Carolina

Job description

This organization is a technology-driven health insurance company built on a full-stack platform with a strong focus on member-centered care. Founded in 2012, it was created to deliver the kind of health insurance experience people would want for themselves—one that feels supportive, accessible, and clinically grounded.

About the Role

You will evaluate the medical appropriateness of inpatient and outpatient services by reviewing clinical information and applying evidence-based guidelines.

Call Rotation

One weekend every 16 weeks

You will report to the Associate Medical Director, Utilization Management.

Key Responsibilities

• Conduct timely medical reviews in alignment with established quality standards
• Make clinical determinations using evidence-based criteria, internal guidelines, and sound clinical judgment
• Clearly and accurately document decisions and communications in workflow systems using appropriate templates
• Ensure documentation is easy for members to understand
• Meet required turnaround times for reviews
• Review escalated cases as needed
• Participate in peer-to-peer discussions with treating providers to clarify clinical information and explain review outcomes, including alternative treatment options when appropriate
• Maintain compliance with all applicable laws and regulations
• Perform other duties as assigned

Requirements

• Board-certified MD or DO
• Licensed in Florida or North Carolina and/or eligible for or active participation in the Interstate Medical Licensure Compact (IMLCC)
• Minimum of 6 years of clinical practice experience
• At least 1 year of utilization review experience within a managed care or health insurance setting

Preferred Qualifications

• Licensure in multiple states
• Board certification in Cardiology, Radiation Oncology, or Neurology
• Experience with care management in the health insurance industry
• Willingness to obtain additional state licenses as needed, with employer support