Insurance Utilization Reviewer Jobs in California

The MSO Physician Reviewer is responsible for ensuring the appropriate utilization of healthcare services while maintaining high standards of patient care. This role involves conducting evidence-based medical necessity reviews for inpatient and outpatient services, assessing prior authorization requests, and supporting appeals and grievance processes. The Physician Reviewer collaborates with healthcare providers, UM team members, and case managers to facilitate efficient and effective care delivery.

In addition to utilization management, this role contributes case management, quality improvement initiatives, and risk adjustment analysis by identifying trends in healthcare utilization, evaluating provider documentation, and ensuring compliance with federal, state, and organizational policies. The Physician Reviewer provides clinical leadership in optimizing care pathways, reducing unnecessary hospitalizations, and enhancing patient safety.

This position requires a deep understanding of medical policies, healthcare regulations, and payer guidelines, including Medicare and Medicaid benefit coverage criteria. The ideal candidate will have strong analytical skills, excellent communication abilities, and a commitment to ensuring equitable, high-quality care. Work is varied, highly complex, and requires a high degree of discretion and independent judgment.

ESSENTIAL JOB FUNCTIONS:

• Evaluate medical necessity, appropriateness, and efficiency of healthcare services using evidence-based criteria (e.g., MCG, CMS, and NCQA guidelines).
• Review and assess prior authorization requests for procedures, hospital admissions, specialty referrals, and medications.
• Provide peer-to-peer consultations with treating physicians to discuss medical necessity determinations and alternative treatment options.
• Participate in the appeals and grievance process by reviewing denied claims and reconsidering medical necessity based on additional documentation.
• Conduct retrospective and concurrent reviews of medical records to ensure accurate risk stratification and appropriate coding and documentation based on patient complexity.
• Analyze Hierarchical Condition Category (HCC) coding and Risk Adjustment Factor (RAF) scores to identify documentation gaps and ensure alignment with CMS risk adjustment models.
• Support provider education on proper documentation and coding practices to reflect complete and accurate disease burden and clinical acuity.
• Participate in chart reviews and audits to ensure compliance with risk adjustment methodologies and HCC coding.
• Evaluate coding trends and audit results to identify undercoded or miscoded diagnoses that may impact risk scores and compliance.
• Work collaboratively with case managers, social workers, and care teams to optimize patient care and resource utilization.
• Support efforts to reduce readmissions and enhance patient outcomes through evidence-based interventions.
• Participate in quality improvement initiatives, such as identifying trends in over- or underutilization, gaps in care, or process inefficiencies.
• Collaborate with clinical and operational leadership to develop protocols and guidelines that enhance patient safety and care quality.
• Review and analyze clinical data to support performance improvement projects and accreditation requirements.
• Performs other job duties as required by manager/supervisor.

• Medical Degree (MD or DO) from an accredited institution.
• Board Certification in a relevant specialty (Internal Medicine, Family Medicine, Emergency Medicine, or another applicable field).
• Active and unrestricted medical license in California.
• Minimum of 3-5 years of clinical experience; prior experience in utilization management, case review, HCC, risk adjustment, or managed care is preferred.
• Knowledge of medical necessity criteria, healthcare regulations, and payer policies (Medicare, Medicaid, and/or commercial insurance).
• Familiarity with UM guidelines (MCG, InterQual, CMS, NCQA, URAC) and utilization review process.
• Experience conducting peer-to-peer reviews and provider education sessions.
• Strong understanding of risk adjustment methodologies (e.g.  HCC coding and RAF scoring) preferred.
• Knowledge of value-based care models, population health management, and healthcare cost containment strategies. 
• Supervisory experience in a healthcare setting a plus.

LANGUAGE:

• Must be able to fluently speak, read and write English.
• Fluent in Chinese (Cantonese and/or Mandarin) preferred
• Fluency in other languages are an asset.

STATUS:

• This is an FLSA exempt position.
• This is not an OSHA high-risk position.
• This is a Full Time position.

NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.