Remote Utilization Management Physician Reviewer

Toney Healthcare; United States; Remote; USD 124,000 - 248,000; Full time

Job summary

Toney Healthcare is seeking a physician reviewer for a remote contract role in Utilization Management. This position focuses on evaluating medical necessity, appropriateness, and efficiency of services by reviewing medical records and applying established guidelines.

Collaboration with healthcare providers and delivering expert care management recommendations are essential. The ideal candidate holds an MD or DO license, with at least 5 years of behavioral health clinical experience and a minimum

Qualifications

• Licensed physician (MD/DO) with an active, unrestricted license.
• Minimum 5 years of clinical experience in behavioral health settings.
• At least 2 years of utilization management or health plan operations experience.
• Familiarity with utilization review criteria, regulatory standards, and managed care principles.
• Strong decision-making, analytical, and interpersonal communication skills.
• Proficiency in EMR and UM platforms (e.g., Jiva or similar systems).

Responsibilities

• Conduct clinical reviews to evaluate medical necessity, appropriateness and efficiency of healthcare services.
• Review medical records, apply clinical guidelines, and collaborate with healthcare providers.
• Provide expert recommendations for care management while ensuring quality standards are met.

Skills

Decision-making

Analytical

Interpersonal communication

EMR proficiency

UM platforms experience

Education

MD/DO license

Tools

Jiva EMR

Job description

Toney Healthcare is seeking a physician reviewer for a remote contract role in Utilization Management. This position focuses on evaluating medical necessity, appropriateness, and efficiency of services by reviewing medical records and applying established guidelines.

Collaboration with healthcare providers and delivering expert care management recommendations are essential. The ideal candidate holds an MD or DO license, with at least 5 years of behavioral health clinical experience and a minimum