Utilization Review Physician

Overview We are seeking a high-performing Physician Reviewer to join our Group Health division. The role is responsible for delivering timely, defensible utilization review determinations across a high-volume, fast-paced environment. Reviews span multiple case types, including preauthorization, appeals, DRG clinical validation, benefit review, and experimental/investigational determinations. Key Responsibilities Perform utilization review for: Preauthorization requests Appeals (first and second level) Independent external reviews DRG validation and clinical review Benefit and coverage determinations Experimental/Investigational (E/I) review Apply evidence-based criteria and guidelines, including: InterQual MCG CMS guidelines (including 2-Midnight Rule) LCD/NCD Client-specific policies Produce clear, concise, and defensible clinical rationales Maintain high accuracy and consistency across determinations Meet or exceed turnaround time (TAT) expectations, including urgent cases Participate in peer-to-peer discussions as needed Collaborate with QA and operational teams to ensure quality and compliance Reviews may be conducted within internal systems or client-specific platforms, depending on assignment and client requirements Performance Metrics High daily review volume with strong accuracy Consistent adherence to client-specific requirements Ability to manage short-TAT and urgent cases efficiently Clear, audit-ready documentation Required Qualifications MD or DO, board-certified in Internal Medicine, Family Medicine, or similar Active, unrestricted medical license Prior utilization review experience, preferably in a health plan or IRO environment Familiarity with InterQual, MCG, and CMS guidelines Strong clinical judgment and documentation skills Ability to work independently in a high-throughput environment Technical Skills Proficiency with standard business tools (e.g., Google Workspace, Microsoft Office) Comfortable working across multiple systems, including internal platforms and client-specific portals Strong navigation and documentation skills within web-based applications Ability to manage multiple systems/screens simultaneously in a high-throughput environment Familiarity with Mac operating systems Work Environment Remote work from home Full-time, Monday–Friday Availability for occasional weekends and holiday coverage for urgent reviews Join our team at Dane Street and enjoy a comprehensive benefits package designed to support your well-being and peace of mind. We offer a range of benefits including medical, dental, and vision coverage for you and your family. Additionally, we offer voluntary life insurance options for you, your spouse, and your children. We also offer other voluntary benefits which include hospital indemnity, critical illness, accident indemnity, and pet insurance plans. Employees receive basic life insurance, short-term disability, and long-term disability coverage at no cost. Our generous paid time off policy ensures you have time to relax and recharge, while our 401k plan with a company match helps you plan for your future. Apple equipment and a media stipend are provided for remote workspace. ABOUT DANE STREET: A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful forward-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers’ Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.