Senior Physician Reviewer - Utilization Management

Clearlink Partners; United States; On-site; USD 138,000 - 207,000; Full time

Job summary

Clearlink Partners in the United States seeks a senior health plan leader to direct medical management and utilization oversight for Medicaid and Medicare programs. You will guide clinical criteria, lead engagements, and drive policy development to improve outcomes.

Responsibilities include ensuring regulatory compliance, presenting findings to executive teams, and shaping population health strategies across complex care populations. Time Zone: Eastern or Central.

Qualifications

• MD or DO with active license in PA or equivalent.
• Master's in Healthcare or Business Administration or related field preferred.
• 10+ years administrative leadership in health plan operations.

Responsibilities

• Conduct clinical review of prior authorization, concurrent review, and retrospective review requests to determine medical necessity and appropriateness of services.
• Collaborate with utilization management nurses and clinical staff to support timely decision-making.
• Review appeals and grievances related to medical necessity and participate in fair hearing processes as required.
• Ensure compliance with federal and state regulations, NCQA/URAC standards, and MCO policies.
• Serve as a liaison between the medical management department and providers, offering guidance on clinical criteria and utilization trends.

Skills

C-Suite strategy

P&L management

Regulatory compliance

Project management

Stakeholder communication

Healthcare analytics

Education

Medical Degree (MD or DO)

Master's in Healthcare or MBA

Tools

Excel

Word

PowerPoint

Visio

Job description

Clearlink Partners in the United States seeks a senior health plan leader to direct medical management and utilization oversight for Medicaid and Medicare programs. You will guide clinical criteria, lead engagements, and drive policy development to improve outcomes.

Responsibilities include ensuring regulatory compliance, presenting findings to executive teams, and shaping population health strategies across complex care populations. Time Zone: Eastern or Central.