Fully Remote
Must have FL, NC or an IMLC
Must live in AZ, FL, FA, or TX
This organization is a technology-driven health insurance company built on a full-stack platform with a strong focus on member-centered care. Founded in 2012, it was created to deliver the kind of health insurance experience people would want for themselves one that feels supportive, accessible, and clinically grounded.
About the Role
You will evaluate the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines.
Hours: 8:00 AM 5:00 PM (local time zone)
Call Rotation: One weekend every 16 weeks
You will report to the Associate Medical Director, Utilization Management.
Work Location:
This is a fully remote position open to candidates residing in Arizona, Florida, Georgia, or Texas. While daily work is completed from a home office, occasional travel may be required for team meetings or company events.
Key Responsibilities
Conduct timely medical reviews in alignment with established quality standards
Make clinical determinations using evidence-based criteria, internal guidelines, and sound clinical judgment
Clearly and accurately document decisions and communications in workflow systems using appropriate templates
Ensure documentation is easy for members to understand
Meet required turnaround times for reviews
Review escalated cases as needed
Participate in peer-to-peer discussions with treating providers to clarify clinical information and explain review outcomes, including alternative treatment options when appropriate
Maintain compliance with all applicable laws and regulations
Perform other duties as assigned
Requirements
Board-certified MD or DO
Licensed in Florida or North Carolina and/or eligible for or active participation in the Interstate Medical Licensure Compact (IMLCC)
Minimum of 6 years of clinical practice experience
At least 1 year of utilization review experience within a managed care or health insurance setting
Preferred Qualifications
Licensure in multiple states
Board certification in Cardiology, Radiation Oncology, or Neurology
Experience with care management in the health insurance industry
Willingness to obtain additional state licenses as needed, with employer support
Equal Opportunity & Accessibility
This organization is an Equal Opportunity Employer committed to fostering an inclusive and supportive environment where individuals can bring their authentic selves to work. Applicants are evaluated solely on qualifications.
Reasonable accommodations are available for candidates who need them during the application process.
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