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 provides expert guidance and solutions to enhance health plans' clinical operations. Our team of over 250 professionals, which includes renowned physician advisors, senior nurse executives, and healthcare specialists, delivers tailored strategies to address organizational needs and improve outcomes for diverse populations. With a deep understanding of the challenges and opportunities faced by risk-bearing entities, we focus on medical management, quality, compliance, accreditation, and beyond. Headquartered in Tampa, FL, we serve clients nationwide across all lines of business, offering trusted expertise and best practices.

Role Description

This is a remote contract role for a Utilization Management Physician Reviewer. Responsibilities include conducting clinical reviews to evaluate medical necessity, appropriateness and efficiency of healthcare services. The role involves reviewing medical records, applying clinical guidelines, collaborating with healthcare providers and providing expert recommendations for care management. The position requires strong clinical knowledge and a commitment to ensuring quality standards are met.

Qualifications

• MD or DO with current, unrestricted license to practice medicine.
• Minimum 5 years of clinical experience in behavioral health settings.
• At least 2 years of experience in utilization management, care review, or health plan operations (preferred).
• 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).