What is utilization management? I am writing this post so that I can learn about it, along with you. I know there are options for a Utilization Management career for physicians, hence this post.

Like most of my posts, I know very little about a topic until I research it and write about it. This opportunity developed into yet another non-clinical income side gig doing medical chart review on the side. I did some work with Nexus – a popular independent UM company.

Nexus didn’t pass my initial sniff test. Then I talked to a recruiter for the company and did some more research and it seems to be a legitimate company.

Companies such as this do independent utilization management consulting work for larger medical health groups. Physicians are hired to perform medical chart reviews and it provides non-clinical side income for these docs.

However, the majority of the work is done by RN’s.

Utilization Management Career

Utilization Management is a method used to determine whether a specific healthcare spending is appropriate in the relevant demographic. This process is also called Utilization Management Review. 

Many of us who have worked for larger medical groups will be familiar with utilization management from the emails we get asking us to reconsider the MRI or CT order. UM is commonly used to justify spending cuts in healthcare which is backed by evidence or guidelines. 

Utilization management and utilization review are technically different terms but they are used interchangeably. But if you want to sound smart during an interview then it’s worthwhile knowing the difference between the two.

You can get a full-time or part-time job in a medical group or insurance company as a physician. And there are lots of Utilization Management Career options listed on LinkedIn and Indeed, as I’ll discuss below.

The key is to ace your job interview. That’s the hard part. If you don’t have any experience then I highly recommend that you do some work with a 3rd part reviewer like Nexus. That way you can land the juicier jobs.

UM Review Customers

Several entities may need to hire a Utilization Management Review company in order to determine if a particular expense is necessary. Examples include:

• Workers’ Compensation
• Group Health Insurers
• Disability Insurers
• Nursing Homes
• Liability (Auto) Insurance
• CMS

Should disability be granted to a patient based on the relevant data on the case? Is the medical claim appropriate for the automobile accident case? Should a health insurance company pay for a particular procedure of the chance of success is low? Should a patient remain on life support?

The medical group or insurance company often has their own internal medical auditors and case reviewers or they will hire an external consultant to do utilization review for them.

See a list of such companies towards the end of this post.

Utilization Review State Regulation

Utilization management and the process of it is tightly regulated by each state and is something that has to be disclosed to the members of each insurance group or healthcare entity.

Physicians are trained how to adhere to these regulations during the hiring and training process. 

Most states will require the physician to have an active license and even work in the particular field in which they do UM work. But others don’t care.

Medical Consulting

Nexus advertises themselves as a medical consulting company and hires their independent physicians to perform medical chart reviews. These are non-clinical jobs, as in, you don’t see patients but review medical charts.

URAC is an accreditor of various health related groups. They verify these entities and certify them. You can enter the name of the particular company you are considering working for in their search field and see if that particular company is accredited.

This particular company has a unique streamlined process of having their medical cases packaged up nicely by their nurses and back office staff in order to simplify the process for the physician.

They only involve the physician once all the relevant information, facts, and treatments have been gathered. These are then compared to evidence-based and guideline criteria and a preliminary recommendation is made which the consulting physician can agree with or disagree with.

This company is paid a set fee by the company who hires them and they will pay their consulting physicians a small percentage of that fee – I believe it comes out to around $75 per case that you review.

UM Work Flow/Volume

The recruiter and the hiring manager made it seem as though there were plenty of cases to go around and usually it’s the doctors who ask for less work.

The process includes an email from a nurse who has compiled the case along with the nurse’s assessment and recommended action. Your job is to review the material and then call the treating clinician to gather more information if necessary.

Supposedly it takes 5-15 minutes to review a case and then you’ll spend a few minutes on the phone with the treating provider and you make your final recommendation which you email back to the nurse case manager.

You are expected to return the emails within 2 hours which is why I suspect many full-time or employed physicians will have a hard time doing this gig.

It takes 90-120 days for the case to be approved and to go through. Once approved, the UM company gets paid and you get a portion of that.

Side-Income Opportunity

There are many opportunities as a medical professional to piece together an income. Reviewing utilization management cases is just one and you have heard me talk about many others on this blog.

What I like about this opportunity is that I can do it from home, I can do it with a laptop and a phone. I also don’t have to be location locked which is a bonus for someone like myself who appreciates location independence.

$75 per case may not seem like much but if the works truly takes about 15-25 minutes then I think it’s a worthwhile income opportunity.

The income is paid to you as an independent contractor. This means that you can write off expenses related to earning this income and you can set money aside in an individual (solo) 401k if you choose to do so.

Ideal Candidate

It’s shocking that we keep hearing about physician shortages and yet our employers offer us very little schedule flexibility. Family Medicine doctors are stuck with the same fucking archaic 8-5 schedule that’s been around since the 50’s.

If you are a full-time employee then I don’t see how this could be a viable opportunity for you unless you are willing to hustle between each patient which is distracting and stressful.

Instead, if you are someone who is piecing together an ideal income stream then this is yet another way to bring in some income without the stress and risk of seeing patients in person.

Utilization Management Risk

What is the risk of performing utilization management review work?

You are providing your expert medical opinion on a case but you aren’t entering a physician-patient relationship.

You would be well-served having an E&O insurance policy to protect yourself in the case of any errors you might make. Or you can ask the UM review company to offer this to you if they aren’t already.

According to Insureon the average E&O policy only costs ~$60/month.

Malpractice Outliers

In reviewing this post and reviewing utilization management cases I learned that there is a very tiny medical malpractice risk which is easily avoided. The key is to not make any treatment or medical recommendations to the patient or the treating provider.

Getting involved in the care is not at all what you’re hired to do so avoid it. Doing so would be as dumb as ordering an EKG for a colleague – but who the fuck would do that??

To protect yourself all you need to do is follow the guideline’s of the UM consulting company. Don’t offer medical practice advice. Don’t discuss the treatment options with the patient nor the treating providers.

Any decent utilization management consulting company will train you how to protect yourself and maintain the proper professional boundaries.

Physician Side Income Opportunity

You can do utilization management as a profession. There are companies which hire full-time, part-time, or consulting internal UM auditors.

Indeed has a fairly extensive listing of jobs for such positions.

You might see many of such jobs being offered to RN’s or LPN’s. There are various legal reasons for that but most companies do this because they want to pay a lower wage.

If you have the right expertise – as you will if you do some UM consulting work – then you can apply for such positions even if you aren’t an RN/LPN.

The income isn’t too bad and I suspect that you could land a remote position if you wanted to.

Searching for Similar Gigs

If you are going to do an online search for similar gigs then you can look for Physician Advisor jobs as well. That’s a good search keyword to use.

Keyword searches will provide you with a ton of excess information but I prefer to perform more directed searches. I would recommend contacting each large insurance or health management group individually in order to search for possible opportunities.

Researching this post I see that United Health Group, the VA, Bethesda Health, and BayCare are all looking for utilization management physicians on a part-time or full-time or consulting basis.

Similar companies to consider are Xsolis, Centene, Admere, and Concentra. These are independent utilization management companies which could be viable UM physician gigs.

I am not sure if NP’s or PA’s would be hired for such roles but I don’t see why not. It would be worthwhile to call up a few recruiters to gauge the need.

Utilization Management Guidelines

When you interview for a job you might be asked what “guidelines” you use to make your decisions. You will likely be sent some sample cases as well in order for the employer to see how well you do.

The gold standard guideline for doing Utilization Review is the MCG. This groups decides what steps should be taken before a certain procedure or test or medication is approved.