Independent Contractor Physician
Utilization Management & Medical Affairs Consultant (1099)
This position is a 1099 Independent Contractor role. The physician exercises independent medical judgment and performs services consistent with applicable contractual obligations, regulatory requirements, and professional standards. Work may be performed remotely and on a project-based basis, depending on organizational needs.
The Independent Contractor Physician provides clinical expertise and medical judgment to support utilization management, care management, quality improvement, medical policy interpretation, and population health initiatives across Medicare Advantage, Medicaid, and Affordable Care Act (ACA) Marketplace health plans. The physician serves as a subject matter expert in evaluating medical necessity, appropriateness of care, regulatory compliance, and evidence-based clinical decision-making while supporting organizational goals related to quality, member outcomes, affordability, and regulatory compliance.
This position requires extensive knowledge of CMS regulations, managed care operations, utilization management principles, clinical practice guidelines, and nationally recognized medical necessity criteria. The physician collaborates with interdisciplinary teams including nurses, care managers, pharmacists, quality specialists, provider relations teams, and health plan leadership.
Independent Contractor Physician Opportunities: Scope of Work
Utilization Management & Medical Necessity Audit Experience
- Conduct audits of pre-service, concurrent, retrospective, and appeal reviews for medical necessity and appropriateness of care.
- Apply evidence-based clinical guidelines, nationally recognized criteria, and health plan medical policies when reviewing determinations.
- Participate in peer-to-peer discussions with health plan or delegate staff.
- Support authorization, coverage, and medical necessity determinations consistent with applicable federal and state regulations.
Medicare Advantage Support
- Experience in clinical oversight for Medicare Advantage utilization management programs.
- Interpret and apply CMS regulations, guidance, and Medicare coverage criteria.
- Review cases involving Medicare-covered services, supplemental benefits, and care coordination initiatives.
- Support compliance with CMS audit requirements and quality improvement activities.
- Assist with implementation of evolving Medicare Advantage policies and operational requirements.
Medicaid Managed Care Support
- Experience in clinical requirements related to Medicaid populations, including children, pregnant members, seniors, and individuals with disabilities.
- Support reviews involving long-term services and supports (LTSS), behavioral health integration, home and community-based services (HCBS), and complex care management programs.
- Ensure compliance with state Medicaid regulations, managed care contracts, and applicable federal requirements.
- Assist in addressing healthcare disparities, social determinants of health, and access-to-care initiatives.
ACA Marketplace Plan Support
- Experience with clinical guidance for commercial and ACA Marketplace plan members.
- Understanding of benefit determinations and medical necessity.
- Knowledge of population health strategies designed to improve quality measures, preventive care engagement, and chronic disease management.
Medical Policy & Clinical Program Development
- Experience with development and periodic review of medical necessity criteria, utilization management policies, and clinical programs.
- Familiarity with policy review committees and medical management initiatives.
- Experience in supporting implementation of value-based care, quality improvement, and population health programs.
Population Health & Care Management
- Experience in collaboration with care management teams to identify opportunities for improved member outcomes.
- Support programs focused on chronic disease management, preventive care, care transitions, and reduction of avoidable admissions.
- Knowledge of multidisciplinary approaches to improving quality, safety, and affordability of care.
Clinical Criteria and Guideline Expertise
Demonstrated experience applying and interpreting clinical review criteria, including but not limited to:
- InterQual® Criteria
- MCG (Milliman Care Guidelines)
- CMS National Coverage Determinations (NCDs)
- Local Coverage Determinations (LCDs)
- Medicare Benefit Policy Manual guidance
- Evidence-based medicine literature and peer-reviewed research
Regulatory and Compliance Knowledge
Strong working knowledge of:
- Medicare Advantage regulations
- CMS utilization management requirements
- Medicaid managed care regulations
- Affordable Care Act (ACA) requirements
- NCQA accreditation standards
- URAC standards
- State insurance and Medicaid regulatory requirements
- Appeals and grievance requirements
- Prior authorization regulations
- Quality improvement and population health frameworks
- Health equity and social determinants of health initiatives
Qualifications – Required
- MD or DO degree from an accredited institution.
- Active, unrestricted physician license in a U.S. state, the District of Columbia, or a U.S. territory (including Puerto Rico, Guam, the U.S. Virgin Islands, the Commonwealth of the Northern Mariana Islands, or American Samoa), with the ability to maintain licensure and meet credentialing requirements applicable to the contracted engagement.
- Minimum of 5 years of post-residency clinical practice experience.
- Experience with managed care, utilization management, or health plan operations.
- Knowledge of Medicare Advantage, Medicaid, and/or ACA Marketplace plans.
- Strong clinical documentation review and medical necessity evaluation skills.
- Excellent written and verbal communication skills.
Qualifications – Preferred
- Previous experience serving as a Medical Director, Associate Medical Director, Physician Reviewer, or Utilization Management Physician.
- Experience with NCQA, URAC, or CMS audit activities.
- Multi-state licensure.
- Experience with risk adjustment, quality programs, and value-based reimbursement models.
- Experience supporting delegated entities, Accountable Care Organizations (ACOs), or Independent Physician Associations (IPAs)
Preferred Areas of Expertise
Experience supporting one or more of the following is desired:
- Utilization Management (UM)
- Care Management
- Disease Management
- Population Health
- Value-Based Care Programs
- Medical Director Functions
- Clinical Appeals Review
- Quality Improvement
- HEDIS Performance Improvement
- Medicare Star Ratings Programs
- Behavioral Health Integration
- Pharmacy Utilization Management
- Long-Term Services and Supports (LTSS)
- Home Health and Post-Acute Care Review
- Transitional Care Management
- Health Equity Programs
- Provider Education and Collaboration
Core Competencies
- Medical Necessity Determination
- Clinical Judgment and Decision-Making
- Evidence-Based Medicine
- Regulatory Compliance
- Physician Peer Engagement
- Quality and Performance Improvement
- Population Health Management
- Healthcare Analytics Interpretation
- Collaborative Problem Solving
- Health Equity and Member Advocacy
- Professional Communication
- Strategic Clinical Leadership
About ATTAC Consulting Group
Founded in 2003, ATTAC Consulting Group is a national firm that health plans, providers, and regulators trust to deliver compliance, audit, and operational solutions that stand up to scrutiny and drive measurable results. ATTAC supports organizations across Medicare Advantage, Medicare Part D, Medicaid, Duals and LTSS, Commercial, and ACA lines of business through five integrated practice areas: Risk Adjustment, Auditing, Provider Networks, Compliance Solutions, and Business Transformation.
How to Express Interest
Send a brief introduction and your CV to the email below. A member of our team will follow up. You can also fill out the form below.
acghumanresources@attacconsulting.com
