Payer and Utilisation Review
Remote, part time friendly, and the most underrated exit in the market.
- Best fit
- Board certified clinicians who can make consistent decisions against written criteria.
- Time to move
- 3 to 6 months
- Indicative pay
- 180k to 290k USD base, senior roles higher with bonus
Insurers and managed care organisations employ large numbers of physicians to review medical necessity, prior authorisation, appeals and coverage policy. The roles are frequently remote, often available at less than full time, and they hire on clinical judgement rather than industry experience. For clinicians who want out of the rota without a two year retraining project, this is the shortest realistic route.
What the job actually is
- Review prior authorisation and medical necessity decisions
- Handle appeals and peer to peer conversations with treating clinicians
- Contribute to coverage and medical policy
- Support quality and cost of care programmes
Skills to build
- Coverage criteria sets and how they are written
- Coding and documentation literacy
- Clear, defensible written determinations
- Comfort holding a decision under pressure
Your first ninety days
- Take independent review organisation cases to build reviewer experience
- Learn the main criteria sets used in your specialty
- Apply directly to plan medical director postings, which turn over constantly
Proof of work hiring managers ask for
- Case review experience with a review organisation
- Committee work on utilisation or quality
- A record of clean, well reasoned documentation
Titles and who hires
Common titles: Medical Director, Utilisation Review Physician, Appeals Physician, Medical Policy Lead.
Typical employers: National insurers, Medicaid and regional plans, Utilisation management vendors, Independent review organisations.
| Role | Level | Indicative band |
|---|---|---|
| Health Plan Medical Director | Mid to senior | 180k to 290k USD |
| Utilisation Review Physician | Entry, often part time | Per case or 150k to 220k USD |
Key signals
- Many of these roles are advertised as remote and some at 0.5 to 0.8 full time.
- Independent review case work is the standard on ramp and can start within weeks.
- Board certification is usually a hard requirement.
