California Licensed Physician Reviewer

Job Summary

A company is looking for a Utilization Management Physician Reviewer.

Key Responsibilities

• Conduct clinical reviews of prior authorization, concurrent, and retrospective requests
• Engage in peer-to-peer discussions and collaborate with healthcare professionals
• Ensure compliance with federal, state, and accreditation standards while guiding UM nurses and clinical staff

Required Qualifications

• Clear and current California MD or DO license
• Proficiency in using electronic health records and UM software platforms (after training)
• 2+ years of experience in a direct patient care setting, preferably in primary care
• Experience in utilization management or managed care setting preferred
• Strong knowledge of clinical standards of care, NCQA requirements, and CMS guidelines