Utilization Management Physician Reviewer - CA Licensed

Job Description

Job Description

Company Description :

Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities.

We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.

Position Responsibilities :

Specific

• Conduct clinical review of prior authorization, concurrent review, and retrospective review requests to determine medical necessity and appropriateness of services.
• Collaborate with utilization management nurses and clinical staff to support timely decision-making.
• Review appeals and grievances related to medical necessity and participate in fair hearing processes as required.
• Ensure compliance with federal and state regulations, NCQA / URAC standards, and MCO policies.
• Serve as a liaison between the medical management department and providers, offering guidance on clinical criteria and utilization trends.
• Participate in interdisciplinary rounds and case review meetings as needed.
• Identify utilization trends and contribute to the development of policies, clinical criteria, and medical management strategies.
• Support quality improvement initiatives and population health programs as needed.

General

Position Qualifications :

Competencies :

Experience :

Physical Requirements :

Time Zone : Must be able to work PST hours

Other Information :

EEO Statement :

It is Clearlink Partners’ policy to provide equal employment opportunity to all employees and applicants without regard to race, sex, sexual orientation, color, creed, religion, national origin, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit-based factor in accordance with all applicable laws, directives and regulations of Federal, state and city entities. This salary range reflects the minimum and maximum target wage for new hires of this position across all US locations.   Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and / or Geographic location. #ZR

Company Description

Clearlink empowers Managed Care Organizations (MCOs) to establish and optimize clinically focused operations. Our specialized expertise spans population health, quality improvement, utilization management, care management, appeals and grievances, and HRA compliance, as well as market expansion through strategic product and network development initiatives.

By integrating advanced technology—from selection to implementation—and offering delegated solutions through Business Process as a Service (BPaaS), we help organizations achieve recurring, sustainable clinical excellence. This approach delivers measurable improvements in healthcare spend, operational efficiency, and member outcomes.

Company Description

Clearlink empowers Managed Care Organizations (MCOs) to establish and optimize clinically focused operations. Our specialized expertise spans population health, quality improvement, utilization management, care management, appeals and grievances, and HRA compliance, as well as market expansion through strategic product and network development initiatives.\r\n\r\nBy integrating advanced technology—from selection to implementation—and offering delegated solutions through Business Process as a Service (BPaaS), we help organizations achieve recurring, sustainable clinical excellence. This approach delivers measurable improvements in healthcare spend, operational efficiency, and member outcomes.