Utilization Management Physician Reviewer – Pediatric Medicaid ACO

Overview

The Utilization Management (UM) Physician Reviewer at Cincinnati Children’s ensures that pediatric Medicaid members receive medically necessary, evidence-based, and cost-effective care. Working within an Accountable Care Organization (ACO) model, this role supports care quality, utilization efficiency, and compliance with Medicaid regulations. The position involves clinical review, interdisciplinary collaboration, and strategic input into population health initiatives. This position is remote with a schedule of Monday through Friday 8:00am-5:00pm EST with minimal weekend and holiday on call requirements.

Responsibilities

• Conduct prospective, concurrent, and retrospective reviews of medical services for pediatric Medicaid members.
• Apply clinical guidelines (e.g., MCG) and Medicaid-specific criteria to assess medical necessity.
• Participate in peer-to-peer discussions with treating providers to clarify clinical information and support appropriate care decisions.
• Collaborate with RN Specialists, Senior RN Specialist and Clinical Director to support integrated care planning.
• Provide clinical input on complex cases involving social determinants of health, chronic conditions, or developmental disabilities.
• Support transitions of care, especially from inpatient to outpatient settings, to reduce readmissions.
• Ensure adherence to federal and state Medicaid regulations, NCQA standards, and ACO performance metrics.
• Participate in the interrater reliability audit process, quality improvement initiatives, and utilization trend analysis.
• Contribute to the development of clinical policies, pathways, and educational materials for providers.
• Advise on utilization trends and opportunities for cost containment and care optimization.
• Support the implementation of value-based care initiatives and pediatric population health strategies.
• Serve as a subject matter expert in pediatric care for internal and external stakeholders.

How to Apply

To apply, please send a letter of interest, including information on research, education, leadership, and diversity and a Curriculum Vitae to Nathan Gohlke, [email protected], Talent Acquisition Physician Faculty Recruiter. Equal Opportunity Cincinnati Children’s is proud to be an Equal Opportunity Employer committed to creating an environment of dignity and respect for all our employees, patients, and families. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, genetic information, national origin, sexual orientation, gender identity, disability or protected veteran status.

Qualifications

• MD or DO degree from an accredited medical school.
• Board Certification in Pediatrics (ABP) required; subspecialty certification (e.g., Pediatric Emergency Medicine, Pediatric Hospital Medicine) preferred.
• Active, unrestricted medical license in the state of Ohio.
• Certified in Utilization Management (e.g., CHCQM-PHYADV from ABQAURP) or willingness to obtain within 12 months of hire.
• Basic Life Support (BLS) certification (if clinically active).
• Familiarity with HIPAA, NCQA, and CMS guidelines.
• Minimum 3-5 years of clinical experience, pediatric experience preferred.
• 1–2 years in utilization management, managed care, or ACO settings preferred.
• Experience with Medicaid populations and pediatric health disparities is highly desirable.
• Proficiency with Epic, MCG, and UM platforms.

#J-18808-Ljbffr Salary: USD 72000 - 108000 per year Experience: 5 years required Apply tot his job Apply To this Job