Utilization Management Physician Reviewer

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art, flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options, including medical, dental and vision plans, for the employee and their dependents, Health Spending Account (HSA), Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.

One Community. One Mission. One California 

As the Utilization Management (UM) Physician Reviewer, you will report to the Medical Director of UM and provide clinical expertise to ensure high-quality, medically necessary, and efficient patient care aligned with regulatory requirements. This role involves making direct decisions in prior authorization, concurrent review of hospitalized patients, and discharge planning.

Key responsibilities include clinical review of prior authorization, concurrent review, and retrospective review requests using critical thinking and established guidelines, interpreting benefit language, and accurate documentation. The reviewer will engage in peer-to-peer discussions with providers, collaborate with other healthcare professionals, and handle appeals and grievances. Ensuring compliance with federal, state, and accreditation standards is crucial.

The position also involves acting as a clinical liaison, participating in case reviews and fair hearing processes, identifying utilization trends, and contributing to policy development and quality improvement. The UM Physician Reviewer will guide UM nurses and clinical staff and stay current with evidence-based medical literature and healthcare trends.

***This position is remote, but will be expected to work PST business hours.  

***This position is part-time, working approximately 20 hours/week, with flexible days/hours.  The schedule includes weekend and holiday rotations ensuring coverage for urgent reviews.

Minimum Qualifications:

- Clear and current California MD or DO license.
- Proficiency in using electronic health records and UM software platforms (after training).

Preferred Qualifications:

- 2+ years of experience in a direct patient care setting, Primary care specialty preferred.
- Experience in utilization management, medical review, or managed care setting preferred.
- Strong knowledge of clinical standards of care, NCQA requirements, CMS guidelines, and Medicaid / Medicare programs and dual eligible populations, and benefit systems preferred.

#UMPhysRev