A Typical Day as a Utilization Management Doctor
- Nisha Mehta, MD
- Jun 10
- 9 min read
A popular option for physicians looking for nonclinical careers or side gigs are utilization management jobs. These positions can offer the opportunity to work from home and have steady income utilizing your knowledge as a physician, but without some of the stressors involved in practicing clinical medicine. Given widespread physician frustrations with the prior authorization system, there can be a lot of trepidation by doctors in our online physician communities considering these positions about whether they’ll enjoy the job, whether they’ll feel pressured to deny care, and whether the peer-to-peer conversations will be contentious or confrontational. Although every physician should decide whether this work is for them, we’ve compiled some anonymous accounts from physicians in this space below to give you a sense of what a typical day looks like when doing utilization or chart review, and what they perceive that the pros and cons of doing this work are.
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What is utilization management, and what kinds of jobs are in this space?
Essentially, utilization management work consists of working with either insurance companies, third party entities that contract with payers, hospital systems, or potentially government agencies to review and evaluate the medical necessity and appropriateness of requested healthcare services and to approve or deny them based on the patient’s clinical picture and medical history, as well as their payer’s policies.
Utilization management companies and positions offer physicians jobs as medical directors in utilization review to oversee claims or requests such as prior authorizations for procedures or imaging, medications, and admissions, as well as length of stay.
Learn more about utilization management jobs for physicians, and where to find them.
Join our chart review database (physicians only) or sign up for our newsletter to find out about available job opportunities.
What are the pros and cons of doing utilization management (UM) work as a doctor?
Pros of doing utilization management work
The most common reasons that we hear physicians asking about or considering UM work are when they are seeking non-clinical career options or need flexibility in their work schedule or the ability to work from home. While every utilization management varies, they generally offer:
A respectable six figure salary with benefits that offers better work life balance than conventional clinical jobs do
Predictable hours (difficult to guarantee in clinical medicine)
The ability to work remotely from anywhere in the US
A less stressful work environment than the clinical realm without the same liability as clinical medicine
The ability to set your hours (sometimes)
An opportunity for you to stay up to date with clinical guidelines and evidence based medicine
An opportunity to advocate for patients when their claims have been denied (fix the system from inside)
Cons of doing utilization management work
The most common frustrations or cons we hear about utilization management jobs are:
Lower salaries than clinical positions in the same field, particularly for specialist physicians
Loss of face to face patient care and relationships
Working remotely means less interaction with colleagues
Peer-to-peer phone conversations which may not always be friendly or collegial, particularly if a request is denied
Work can feel monotonous and algorithmic
Some jobs require after hours or weekend work
Will I be forced to or pressured to deny lots of cases if I do utilization management work?
While there have been accounts to the contrary, most physicians in this line of work on our community express that they do not feel pressured to decline claims. They deny that there is a set percentage that they are expected to deny, or that they get pushback when they approve something expensive. They state that the emphasis is on making sure that the claim is in accordance with the payer plans and evidence based practice.
What does a typical day in the life of a utilization management physician look like?
The following combines the accounts of several anonymous physician members of our physician communities. Of course, every job is different, so it’s important to ask questions about the things that matter to you with the company or entity you’re considering working for.
The primary responsibilities during the day tend to involve:
Reviewing updates to policies and procedures and meeting with the rest of the utilization management team: This could include things like reading policy updates or updates to guidelines or evidence based medicine relevant to the cases you tend to review, having team meetings to discuss cases with other members of the team including case managers or other clinical reviewers or medical directors, or reviewing alerts from insurance companies or other payers or hospital systems for updates or policy changes
Case Reviews: You have to review requests for procedures or imaging, other prior authorizations for workups, hospital admissions, length of stay, or similar. Physicians state that most of the cases are for routine indications such as pain or common surgeries and they are able to review these cases quickly, with the average case taking between 5-10 minutes. You are typically expected to do about 10 cases an hour. There is usually software that hands you these one at a time, along with relevant data such as office notes, labs, imaging results, and insurance plan documents about their coverage, that makes the work relatively efficient. You’ll have to determine if these requests are in line with guidelines and evidence based medicine as well as the patient’s particular health plan. You’ll also have to determine if they are medically necessary. Once you’ve made a determination, you’ll write up and submit a determination of approval or denial.
Peer to Peer Reviews: Most UM physicians say they spend about 25-50% of their time on the phone with other clinicians (not all of whom are physicians, but may be an MA, an NP or PA, a case manager, an office manager, or someone else involved in the patient’s care). They say that most calls are usually pretty uneventful and quick, and many times may just involve adding information to the request such as information that was omitted that would make it okay to approve the request or requesting additional documentation. However, they do say that some calls can be contentious, especially if the decision to deny a request is upheld and the clinician is unhappy with the outcome. Most UM physicians are quick to point out that there really are cases where a specific request is unindicated and simply wanting a study if it’s not in accordance with evidence based medicine is not a reason to approve it. This is for most physicians the most unpleasant part of the job. One thing that they state can be particularly uncomfortable is when the physician on the other side of the call has more training or expertise in a specific area, or is a subspecialist that has a niche practice or has very specific practice patterns that may deviate from normal practice patterns, but is convincing regarding their rationale. Most UM physicians say they are quick to defer to the specialist in these cases.
More complex case reviews: A small percentage of cases may require extra scrutiny and work, or the generation of more complex reports. These usually happen when denials are escalated or there is a particularly high value claim that is being called into question. These may require more research into standard of care or more extensive conversations or asks for documentation. The documentation on these reports is typically more tedious, as they need to be legally and medically sound if called into question.
What kind of hours (and how many) do I have to work?
This is company and role dependent. Most companies are looking for at least a part time commitment to ensure that they can complete the volume of reviews they have, and count on your presence. Therefore, most of these positions are not a “log on when you want” type opportunity, but rather a commitment to complete a certain amount of hours a week or month.
The most common arrangement we see are part time positions with a minimum of 20 hours/week committed, or full time positions at 40 hours per week. Some jobs will allow you to average those out over the month so that you can work more or less in a given week, whereas others will require you complete those hours within a particular week.
Some of them will require that the work is done during normal business hours, whereas others don’t care as much when you do your hours, so long as they’re done and in accordance with the guidelines. In many cases, they will at least want to know when you’re planning on working over any given week to ensure they have coverage and they know when to schedule your peer to peer calls, so you’ll likely be required to submit a weekly schedule ahead of time with the hours you’re planning on working if you’re on a non-conventional schedule.
Specialist physicians tend to have more flexibility to ask for special arrangements because of supply and demand issues.
Some companies require evening or weekend work to be a portion of the hours you commit to, depending on their clients (what time zones they are in and what kinds of approvals you need to do and how time sensitive they are). They may also require that a certain number of your hours are on a particular day of the week, especially if there’s one like Friday that most people tend to want off.
Companies vary in how much paid time off they give and whether they pay for breaks during the work day (most do).
Connect with companies looking for physicians to do utilization management work. (It’s completely free to connect, but only open to members of our online physician community.)
What are the pay and benefits like?
As you might imagine, this will also vary depending on the company, as well as your work requirements and specialty.
Most companies in this space tend to pay employees, whether full time or part time, as W2 employees.
Pay amongst specialties varies, but most UM physicians make between 100-180/hour, with specialists and harder to recruit specialties tending to be the specialties that make on the higher end of that range.
Many of these companies offer full benefits, even for part time employees, including access to retirement plans and possible contribution matching, health insurance, vision and dental insurance, and potentially disability and life insurance. There may be other corporate perks as well.
What else should I know about the application process?
We discuss finding opportunities and what makes you a desirable candidate in more detail on our dedicated article about finding UM jobs as a physician. However, for planning purposes, you should know that if you want to make a switch, you should start as early as possible. Onboarding can take time and may require getting additional state licenses. Most utilization management companies have a formal training program for a few weeks that you must participate in; while these are often remote, they tend to have set hours, so you need to plan accordingly. In general, as more physicians look to shift to nonclinical work, companies can be inundated with applications, so expect it to take some time between when you apply, get interviewed, get onboarded, get trained, and actually start. That said, many companies are actively seeking physicians to do utilization management work. Many physicians say it took almost a year for them to begin working as a utilization management doctor once they started looking for these jobs.
Connect with companies looking for physicians to do utilization management work. (It’s completely free to connect, but only open to members of our online physician community.)
Conclusion
There’s a lot of myths about what it means to be a utilization management physician, and we hope that this article based on anonymous accounts from physicians working in UM helps to clarify what work is asked of from these doctors, claims about percentages that need to be denied, and how physicians feel about the work. As always, jobs will vary, so ask questions about the things that matter to you before deciding whether any individual position is the right one for you!
Related chart review resources for physicians
Learn more:
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