UM Medical Reviewer, PRN

Location: California

UM Medical Reviewer, PRN page is loaded## UM Medical Reviewer, PRNlocations:
California, USAtime type:
Variable time posted on:
Posted 2 Days Agojob requisition :
M102227
** Job Description Summary
** The Physician Reviewer in Utilization Management (UM) is responsible for conducting clinical reviews of medical necessity, appropriateness, and efficiency of healthcare services, procedures, and hospital admissions. The reviewer ensures that clinical decisions align with established evidence-based guidelines, regulatory requirements, and organizational policies to promote optimal healthcare outcomes and cost-effective care.
** How will you make an impact & Requirements
***
* Key Responsibilities:

*** Conduct prospective, concurrent, and retrospective clinical reviews of medical
* services to determine medical necessity and appropriateness.
* Utilize evidence-based criteria (e.g., MCG, Inter Qual, CMS guidelines) in evaluating requests for services.
* Collaborate with nurses, case managers, and other healthcare professionals in the UM process.
* Provide timely peer-to-peer consultations with requesting providers to discuss clinical decisions and alternative care options.
* Participate in appeals and grievance processes by reviewing denied cases and providing justification based on medical necessity and standards of care.
* Ensure all reviews are performed in compliance with federal and state regulations, accreditation standards (e.g., NCQA, URAC), and organizational policies.
* Document decisions clearly and accurately in the appropriate systems.
* Identify patterns of inappropriate utilization and collaborate in quality improvement initiatives.
* Participate in staff training, UM committee meetings, and policy development as needed.
*
* Qualifications:

*** Medical Degree (MD or DO) from an accredited institution.
* Board certification in a clinical specialty (e.g., Internal Medicine, Family Medicine, Pediatrics, Psychiatry, etc.).
* Active, unrestricted medical license state required
* Minimum of 3–5 years of clinical experience; experience in managed care, utilization review, or insurance industry preferred.
* Familiarity with UM guidelines (e.g., MCG, Inter Qual), Medicare/Medicaid regulations, and health plan operations.
* Excellent clinical judgment and decision-making skills.
* Strong communication and documentation skills.
* Proficient in using electronic medical records (EMRs – Athena a plus) review platforms, and Microsoft Office Suite.
** Preferred

Skills & Experience:

*** Experience working in a health plan, insurance company, or third-party administrator (TPA).
* Knowledge of value-based care, population health, and cost containment strategies.
* Ability to manage multiple tasks and meet deadlines in a remote or fast-paced environment.
** Compensation:**$134.55to $201.83

At Care More Health, we provide effective Advanced Primary Care and Palliative Care by seeing the whole person — body, mind, and spirit. We do it with doctors and nurses who provide personalized and compassionate care, nationally recognized disease prevention and management programs, and healthy-living plans. It helps patients get healthier, while receiving the healthcare experience they’ve always wanted.

Mosaic Health is a national care delivery platform focused on expanding access to comprehensive primary care for consumers with coverage across Commercial, Individual Exchange, Medicare, and Medicaid health plans. The Business Units which comprise Mosaic Health are multi-payer and serve nearly one million consumers across 19 states, providing them with access to high quality primary care, integrated care teams, personalized navigation, expanded digital access, and specialized services for higher-need populations.

Through Mosaic Health, health plans and employers have an even stronger care provider partner that delivers affordability and superior experiences for their members and employees, including value-based primary care capacity integrated with digital patient engagement and navigation. Each of the companies within Mosaic Health provide unique offerings that together promise to improve individuals' health and wellbeing, while helping care providers deliver higher quality care.

For more information, please visit  Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.

If you require an accommodation for the application or interview process, please let us know and we will work with you to meet your needs. Please contact  for assistance.
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