Lecture by Dr. Jonathan Vitale – Episode 436
In today's presentation, Dr. Jonathan Vitale describes the truth about landing your first utilization management job.
Drawing from his own experience, he unpacks what utilization management really involves, why it’s become one of the most popular remote physician careers, and the realistic steps doctors can take to get started
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Understanding UM Work
Vitale defines utilization management as a structured process used by insurers, health systems, and independent review organizations to ensure that care is appropriate, efficient, and consistent with benefits and medical-necessity criteria. Day-to-day work typically centers on prior authorizations, concurrent reviews for hospitalized patients, and occasional retrospective reviews, all of which are handled in a remote setting with a steady caseload rather than a packed clinic schedule.
He notes that most full-time UM physicians in primary care specialties can expect a base salary in the low- to mid-$200,000s, with potential bonuses, stock, and merit increases. Importantly, working nights and weekends, and worrying about malpractice are largely off the table.
Breaking into UM Careers
For physicians without prior UM experience, Vitale recommends starting with small 1099 case-review gigs through independent review organizations to build real experience for your CV. He points to the NAIRO.org member list as a practical place to find part-time UM jobs, then describes how six to twelve months of that work can position someone for a full-time medical director role at a large insurer.
From there, he stresses persistence:
- daily applications on sites like Indeed, LinkedIn, and insurer career pages, plus,
- strong CV and interview preparation.
And he explains that timing, sending a high volume of applications, and comfort with rejection are often the deciding factors, not a lack of clinical competence.
Summary
Vitale’s talk offers a clear, realistic roadmap into utilization management for physicians who want remote, lower-stress work while applying their medical training and experience. Listeners can join his Remote Careers for Physicians community or seeking coaching through drjonathan.com, via email at drjonathan@drjonathan.com, or by searching Facebook for Remote Careers for Physicians.
NOTE: Look below for a transcript of today's episode.
Links for Today's Episode:
-
- Contact Dr. Jonathan Vitale: drjonathan@drjonathan.com
- Dr. Jonathan Vitale's Website
- Facebook for Remote Careers for Physicians
- Find Jonathan's full lecture and 18 others at Highlights of the Nonclinical Career Summits.
- Nonclinical Career Academy
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Transcription PNC Podcast Episode 436
The Truth About Landing Your First Utilization Management Job
- Lecture by Dr. Jonathan Vitale
Dr. Jonathan Vitale: Thank you so much, John. It's an absolute pleasure and privilege to be here. And I always love coming to these sorts of events. John was also kind enough to have me on his podcast. And so thank you for that. And it's always a pleasure to talk about this topic, which is near and dear to my heart, which is physician career transitions, specifically, as I'm going to talk about tonight, remote careers and utilization management.
So let me talk about my I'm going to talk about myself a little bit, and how I got to what I do today. And then I'm going to talk about what is or utilization management, I'll talk about the types of the day to day of a doctor, then the compensation, which everybody's very interested in the application process, how to get experience so that you can apply how to build your CV, how to get appropriate coaching if you need that. And then I'm happy to answer any questions.
Again, I'm Dr. Jonathan Vitale, I'm a board certified family physician, I had a pretty traditional journey to being a family physician. And today, I'm a manager of utilization management physicians at one of the top health insurance companies in the country. I'll tell you a little bit about my journey on how I got there.
I had a pretty typical path to becoming a family doctor, except I picked up a master's in counseling before medical school. And after medical school, I did residency in Chicago and family medicine. And then I moved to New York City, where I live now, for my first attending job at kind of a concierge clinic that I thought I would enjoy, because I really did not like the traditional doctor's schedule, their traditional working nights and weekends working a lot.
And after doing that, for really just a few years, I decided that I needed to transition, I was very fortunate. And one of the very fortunate people to have heard about very early on, I actually knew about it when I was in high school, because my brother has type one diabetes, and my parents would always be getting rejections from the insurance companies. And I always wondered why.
And I would ask my mother, and she would tell me that they had doctors working at insurance companies making decisions. I'm one of the very lucky people who knew about um and was intrigued by it very early on, although that's probably only about 1% of um docs who knew what it was before they became burnt out. But something that always, another thing I wanted to say is welcome to everybody to this amazing community.
The community of non-physician, of non-clinical, or as I call us, non-traditional physicians, is a very, very warm community. It's a very welcoming community. And it's a community of people who really want to help you transition into a job that you love.
And what I just, what I've kind of came to the realization of early in my medical career was that doctors in general from day one of saying you're pre-med, day one of deciding you're pre-med, you are overworked, you are underappreciated, you are underpaid. And that continues for the 10 or 15 years it takes you from day one of pre-med to becoming and attending. And I think that what happens is a lot of people just become very used to being treated that way.
And doctors, that's why so many doctors do much, do so much extra work for free. I mean, name another profession where you work extra hours and aren't paid for it. Or you're doing your charts at night, not paid for it. Or on weekends, not paid for it. Or taking call nights and weekends, not paid for it. And I never understood that.
And it always bothered me immensely because I think physicians are amazing. We have so much to offer and we should be fairly compensated and respected for that. And that was one of the things that got me into wanting to transition.
And also my background as a counselor is really what got me interested in, and after I kind of got there, coaching other physicians on how they too can get there. what I do today, in addition to my utilization management job, is I also coach physicians. Specifically, I help people get remote careers, mostly in but I do know about other fields as well.
So you can always reach me at drjonathan.com or email me at drjonathan@drjonathan.com. Or please, as John mentioned, join our Facebook group of Remote Careers for Physicians, which is a wonderful community of physicians helping out physicians who are interested in remote careers. I always joke that I was into remote careers before being in a remote career was cool.
I started the Remote Careers Facebook group in 2018. And since the pandemic, it's exploded. Nowadays, everybody wants a remote career, it seems like. And I think it's as best of a time as any to transition into this field.
But I'm especially going to be talking about tonight, Utilization Management. what is Utilization Management? It's also called Utilization Review, but for tonight, we're going to call it UM or Utilization Management. the best definition I could find is it's a systematic approach used by health care organizations, insurance companies, and other stakeholders to evaluate and manage the appropriateness, efficiency, and cost effectiveness of health care services. the primary goal of UM is to ensure that patients receive the right care at the right time in the right setting, while minimizing unnecessary treatment costs and potential harm.
Another way I think about it is we reduce fraud, waste, and abuse, probably mostly waste. Probably 80% of what we deal with are waste, wasteful orders, or wasteful requests, etc., which we'll talk more about later. there's really three main buckets of UM companies.
And I always like to be very general about how I describe this, and then we'll move down into some specifics. there's private UM companies. These are those third-party companies that I always talk about, which are good companies to try to get experience with.
Those are superfluous. Many of them are listed in nairo.org, which we'll talk about later. Then there's health care systems, or hospital systems, which also hire UM nurses and UM doctors.
And then probably the most common for full-time docs would be insurance companies. insurance companies also hire their own UM nurses, their own UM doctors, their own UM physical therapists, pharmacists, etc. And these are the big names you've all heard of.
This is your Aetnas, your Humanas, your Uniteds, your Anthems, your Kaisers. They all hire their own UM clinicians to work for them. And what you do in UM is essentially usually one of three things.
There's prior authorizations. Everybody's heard about a prior auth. Everybody knows what a prior auth is. There's certainly a lot of attention in the news nowadays around prior auths and reducing the paperwork associated with prior authorizations. But there's a lot of UM that goes along with that. a physician orders a test, a study, a medication, a home health service, which I'm involved with.
And the prior auth physician determines whether or not that meets certain criteria, and most importantly, whether or not it is medically necessary. That's prior auth. And there's also concurrent reviews.
This is very common in the hospital setting. If when we're talking about bed days and how long a patient can stay in a hospital, how is this patient doing day to day? They're checking in to see if they can extend and give them more days or if they're suitable to go home or go to rehab or go to a different level of care.
That's called concurrent reviews. And then the final one is probably the smallest, and those are retrospective reviews. Those are done when the service has already been provided, already been rendered, and now they are reviewing it on the back end to see if it was medically necessary and if it fit the guidelines.
The reason why a lot of people go into UM is really primarily, I would say, what attracts people is the lifestyle, meaning it's typically remote. It's typically 40 hours a week when you're in a full-time gig. It's typically a salaried position, typically, not always. Also, you have very low liability. Basically, you're not practicing medicine. you don't need malpractice insurance.
You carry errors in admissions insurance. It's interesting work. It's a very comfortable pace, and you're not patient-facing. So it's a much lower, lower stress job. And you have typically, generally speaking, nights and weekends off and holidays off. In terms of compensation, and this is a very hot topic, I'm asked this all the time, there's really not good national average data. I will tell you what I see because I look at hundreds of positions for UM all the time. And I would say, and there's a very big range. I'm sorry, I can't be more specific.
But generally, if you're a full-time UM physician and you're in one of the primary care areas, you're typically talking about the lower to mid $200,000 range as a W-2 base salary. I've seen it all the way up to 300, maybe a little bit more for people like oncologists or people with very, very high demand skills. But keep in mind, in addition to that, first of all, that's 40 hours a week.
But in addition to that base salary, we're also talking about merit increases, which typically happen every year on the order of usually around 2% to 3%, but it can be more than that. In addition to that, you're talking about quarterly or annual bonuses. And you're also talking about usually a stock gift if you work at a large insurance company, as I do.
There's a lot of additional compensation that's also very attractive. always keep that in mind. I always like people to keep that in mind when they're saying, hey, but I make so much more money than that.
I say, yeah, but you probably work 80 hours a week and are 100 times more stressed. keep that in mind. Some other things I wanted to talk about is basically the process of what your typical day looks like when you're doing most UM.
And I'm going to talk about full-time jobs, and then we'll talk about the gigs. Okay, the full-time jobs, which are kind of the cream of the crop of which are those very, very highly desired 40-hour-a-week full-time jobs, which are very competitive, is you typically have a set number of cases that you're reviewing per day. There's nothing, you're not chained to your desk.
It's not like it is in most clinical practices where every second of your time is scheduled and monitored, and you need to be patient-facing in order to bill. No, I mean, you typically have a set number of cases that you're attempting to get through. Sometimes there's peer-to-peers involved as well.
And sometimes you have a few meetings and things like that when you're at the kind of the basic medical director level, medical director's entry level for utilization management. And then there are also opportunities to grow, kind of like Marie was talking about at MSL. There's some opportunities to grow into more of a team lead and manage a team.
And then there's opportunities for being a manager and managing a larger team, which that's what I do. I manage a large team of UM physicians, and I also hire them and interview them. And then there is also the opportunity to branch out into other fields in health insurance companies, which other people are talking about in their lectures tonight.
I won't get too much into that. something I do want to talk about is some of the other gigs in utilization management. there are small companies, usually these third-party companies that exist, and they do certain reviews.
They may be doing reviews for a certain procedure. They may be doing reviews for a certain medication. And what they'll do is they'll have a panel of doctors of 1099 or independent contractor physicians who they will reach out to and say, we have this request for this medication.
Can you review it for us? And we'll pay you X number of dollars. It's usually very low, by the way. It's usually like $20, $30. And those companies exist, and they are superfluous. And a lot of physicians look at that and say, I'm not doing that. And I say, you don't understand. You have to do that. You do that to get experience.
You don't do that to make money. You do it as a side gig while you're still in your other clinical job so that you can get some experience under your belt in doing UM so that you can put that on your CV. And that's why you do those roles for 6 to 12 months so that you can actually have some experience to talk about when you apply for those big full-time positions.
Now, how do you get these gigs? It's pretty simple. I talk about it all the time on remote careers. You just go to nairo.org, N-A-I-R-O, the National Association of Independent Review Organization, .org. You click on Members. Again, you don't become a member.
You click on Members, and you scroll all the way down, and it lists the logos of 20 or 30 of these companies. You go to every one of those individual company websites, and you navigate the website, and you click on Apply to be on the Physician Panel. And you submit your CV to every one of them.
I guarantee you at least two or three of them will contact you within the week and put you on their panel. And that means you are now getting UM experience. that's a great way to get UM experience. Yes, it does take a lot of time to sign up for all of them. I never said it would be easy. And it's a great way to get your first step in the door.
I always say this. My specialty is helping doctors who have no other experience, no outside experience, normal, average doctors. I guess no doctors average.
We're all awesome. But I would say regular doctors into the world of UM who have no prior or outside experience, no connections, nothing else. That's what I help people to do because that's how I got involved.
After you have that, the next thing that you need to do is after you've done that for six or 12 months, that's when you're able to actually apply to these full-time UM gigs that most people want. Like every other non-traditional job, especially nowadays, it is very competitive. However, what I can say, and I think this is really, really important, that it's not that it's super, super competitive, which it is, but it's more so the fact that doctors are used to it being ridiculously easy to get a job.
If you're a regular, traditional outpatient family doctor, been working at your clinic for 10 years, and now you want to move to a different city next week and you want a job there, all you have to do is send out an email with your CV to a couple people and you'll probably get 100 job offers the same week. That's how it is for clinical doctors. We're very spoiled, but that is not how it is when you make the transition.
That's something that you really have to psychologically get behind and understand that for many people, it's going to take a year, sometimes two years, to actually make that transition, to get enough applications in, to get rejected enough. As you always hear me on Facebook, for those who follow me, I always say to people, you haven't been rejected enough yet. That's your main problem.
It takes a lot of rejection, a lot of getting ghosted before you get your position, but you will get there. Don't worry, you will get there. It's just a process.
The thing that you also want to do is you want to work on your CV, and there's lots of coaches to help you with this. I'm one of them, but there's certainly many other coaches who can help you with this, many of whom you're hearing about these past three nights. You also want to work very hard on your interview skills, and coaches can help you with that.
I can certainly help, as can all the other coaches. What you want to do is you want to make it your job to, every day, apply and send in your CV to openings for utilization management. These are typically listed.
I like to keep things simple. They're typically listed on Indeed, on LinkedIn, and also on the private insurance company's websites. What I encourage people to do, who are interested in a life of is every single day, it only probably takes about an hour out of your day, you want to be visiting every one of those websites.
You want to be searching. You want to save this in your search. You want to be searching for medical director, utilization review, utilization management, utilization review physician, physician reviewer, MD reviewer, all those synonymous terms that a lot of companies use.
Then, you want to be looking for those positions, and you want to be submitting your CV. Yes, absolutely, networking is great. If you can do that, if you have any contacts, if you network through LinkedIn, if you network through one of these conferences, through a seat conference, for anything like that, that's wonderful.
What I can tell you is that in the UM world, things move very quickly. That works both in your favor and against your favor. Let me be more specific about timing. I always talk about, when I first got into about how I applied for a year and got rejected probably over a thousand times, at least hundreds and hundreds of times. I was rejected or ghosted. What I've learned now that I'm a hiring manager for UM is that timing is everything.
Let me be more specific on that. Many times, these UM companies, especially the insurance companies, which are the largest employer of UM docs, are always trying to get more business. They're always trying to get more contracts. They're always trying to expand their geography. They're always trying to do UM for another network, for another geographic location. They have business folks who, that's all they do, is try to broaden their business.
As you guys know, anybody who's worked in business, business is a tough field. Things move very fast and sometimes very unexpected. You can literally be at a job, or I can literally be in a position, and I can literally hear one day, hey, you know what? We finally got that contract we've been after for eight months or 12 months.
Now we have a need for five other doctors on your team, as we call them FTEs, full-time equivalents. Five FTEs on your team, and you need to get them up and trained and ready to go as soon as humanly possible, because we're going to start getting UM cases from that network in three months.
We got to be ready to go. This is the kind of thing that happens. What am I doing? We're posting it on our website, and the first good CV I get, who's board certified, who's got some decent experience, I am scheduling them for an interview. But let me tell you what, though. That same candidate, if they applied two weeks before, they probably would have gotten either ghosted or rejected.
Again, I don't write the rules, I'm just telling you what they are. The HR oasis for these big companies, don't assume that they're going to put your CV on hold. Don't assume that every job listed currently is available.
That's another one. Don't assume that you're going to even hear back. That's why my best advice is it's a numbers game. When the new positions come up, that's why you have to be checking every single day. You need to be applying for that new position, because that happens all the time in which is good news for people like us, because it means there are definitely jobs that open up and that need good folks. But the flip side of that, though, is let's say that you have 20 years of UM experience, 20 years of clinical experience.
You're the most competent UM doc in the world, and you reach out to me and send me your CV today. I'd say, I can't do anything with this, but thank you, because we don't have any openings. I'd say, just keep monitoring our website. That's how it works at a lot of the large health insurance companies. Yes, there's other things that happen at smaller companies where they may keep things on hold, but I'm just telling you how it works at the large health insurance companies. That's why I always say to people, and you see me say this on Facebook and everywhere else, apply, apply, apply.
And the clients that I work with, one of the biggest hurdles we have to get over is they fear rejection so much. I say, my gosh, I was rejected hundreds of times. I didn't even get to rejected status.
I was just ghosted. My application would just go into the big dark oasis, and nothing ever happened. And I just got over it.
And after a while, I started celebrating rejections, because every rejection is one step closer to an acceptance. And these jobs, especially UM jobs, as we were talking about, as Marie was talking about MSL jobs, they're very competitive. There's more docs than ever that are looking to make a transition.
The other thing is doctors are looking to make a transition earlier and earlier in their careers. My team, I would say, on a whole, at this point, we have about 25 docs on my team, and we are all stages of our career. There's people who are in their early career, mid-career, late career.
There's people who are post-retirement who just do this for fun, if that tells you anything about the job as well. it is difficult to get a position, but it's definitely not impossible. It just takes persistence.
And there's so many people who are there to help you. Let me talk a little bit about, I know there's a question on peer-to-peers. Let me talk a little bit about the ethics of utilization management.
Again, utilization management gets a bad rap sometimes for being, oh, we're just there to deny care and just to improve our profits. And nothing could be further from the truth. First of all, UM physicians do not get any sort of incentive, financial incentive, for denying patients.
That's illegal, and it does not exist. And especially the company I work for, which is a very ethical company, it just does not exist. I don't care one way or the other what decision a doctor makes.
It makes zero difference to me. All that I care about is that the quality of their review is very high, and the quality of their explanation is very thorough and very high, et cetera. what we do, so I work in the world of Medicare Advantage Utilization Management.
So we're working within the confines of what the Medicare Advantage Benefit provides. an example of this is a lot of people, a lot of doctors don't understand or don't know, and I don't blame them. They don't know sometimes what the benefits provide.
They don't know what the insurance benefit provides a patient. They may not know what the Medicare Advantage Plan benefit provides a patient. An example would be if somebody was ordering something that's not covered in the Medicare Advantage Benefit, something like custodial care or what we call unskilled home health aid support for a patient.
That is not something that the MA Benefit provides. CMS does not pay for that. It is not covered. That is not something I can authorize under any circumstances because it's not part of the benefit. that would be an example. If we were to do a peer-to-peer, what I would be saying to that physician is, hey, look, I know you ordered this, the home health aid for this patient, but are you aware that there's no, from what I can see at least, there's no other skilled need in the home.
They don't have a need for skilled nursing, for skilled physical therapy, occupational therapy, and CMS care is short-term and intermittent home care. I cannot authorize this because that's custodial and it's just not provided by the benefit. And I'm just very open about it.
And then what we do is we go out of our way to try to be of other service. I'll say, hey, have you considered maybe getting a social worker to help this member? Or perhaps I can get a case manager to help and see if there's other resources. Or maybe there's some local Medicaid resources we can help with. That's kind of that all or nothing. Now, then there are also peer-to-peers where, let me just start by saying this though.
When I do a peer-to-peer or anybody on my team does a peer-to-peer, there's a few reasons we're doing it. The biggest reason we're doing it is we want to make sure we have all the information that it's correct. That's why we're doing it.
We're not calling them up to just say, hey, too bad, sorry, so sad. I don't care what you have to say. Not at all.
We are physicians and those physicians in the field are our colleagues. They are not our patients. We have a great deal of respect for these treating physicians.
We have a great deal of respect for their thought processes. And what we're doing when we call is I want to know, make sure that I have all the information that it's correct. Nine times out of 10, the physician has additional information that's not in the documentation.
And we say, hey, thank you so much for letting me know that. I didn't know that this patient can only can only walk 10 feet. I thought it said 1,000 feet. I'm so sorry. I will change that right now. We'll be happy to approve those home PT visits for your patient.
That's what we're doing. The other thing is if we're making a decision, let's say we're granting four out of the requested eight home physical therapy visits, because our physical therapists and doctors, by the way, we also have all cases reviewed by PTs before they come to doctors, think that fewer are necessary. But I call up and the doctor tells me, yeah, but you have to understand that this member doesn't have a caregiver.
Nobody's helping them with their home exercise program. I don't know if that was in the documents, but I think they really need more cases like that. Absolutely. We are happy to do that.
Keep in mind that yes, there are some contentious spirit appears, but I would say, and I'm not making this up, that's less than, well less than 5%. Because generally these physicians they understand that we have a job to do and they're very happy that we're able to explain to them our thought processes is and why we're making these decisions.
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Transcription PNC Podcast Episode 436
The Truth About Landing Your First Utilization Management Job
- Lecture by Dr. Jonathan Vitale
Dr. Jonathan Vitale: Thank you so much, John. It's an absolute pleasure and privilege to be here. And I always love coming to these sorts of events. John was also kind enough to have me on his podcast. And so thank you for that. And it's always a pleasure to talk about this topic, which is near and dear to my heart, which is physician career transitions, specifically, as I'm going to talk about tonight, remote careers and utilization management.
So let me talk about my I'm going to talk about myself a little bit, and how I got to what I do today. And then I'm going to talk about what is or utilization management, I'll talk about the types of the day to day of a doctor, then the compensation, which everybody's very interested in the application process, how to get experience so that you can apply how to build your CV, how to get appropriate coaching if you need that. And then I'm happy to answer any questions.
Again, I'm Dr. Jonathan Vitale, I'm a board certified family physician, I had a pretty traditional journey to being a family physician. And today, I'm a manager of utilization management physicians at one of the top health insurance companies in the country. I'll tell you a little bit about my journey on how I got there.
I had a pretty typical path to becoming a family doctor, except I picked up a master's in counseling before medical school. And after medical school, I did residency in Chicago and family medicine. And then I moved to New York City, where I live now, for my first attending job at kind of a concierge clinic that I thought I would enjoy, because I really did not like the traditional doctor's schedule, their traditional working nights and weekends working a lot.
And after doing that, for really just a few years, I decided that I needed to transition, I was very fortunate. And one of the very fortunate people to have heard about very early on, I actually knew about it when I was in high school, because my brother has type one diabetes, and my parents would always be getting rejections from the insurance companies. And I always wondered why.
And I would ask my mother, and she would tell me that they had doctors working at insurance companies making decisions. I'm one of the very lucky people who knew about um and was intrigued by it very early on, although that's probably only about 1% of um docs who knew what it was before they became burnt out. But something that always, another thing I wanted to say is welcome to everybody to this amazing community.
The community of non-physician, of non-clinical, or as I call us, non-traditional physicians, is a very, very warm community. It's a very welcoming community. And it's a community of people who really want to help you transition into a job that you love.
And what I just, what I've kind of came to the realization of early in my medical career was that doctors in general from day one of saying you're pre-med, day one of deciding you're pre-med, you are overworked, you are underappreciated, you are underpaid. And that continues for the 10 or 15 years it takes you from day one of pre-med to becoming and attending. And I think that what happens is a lot of people just become very used to being treated that way.
And doctors, that's why so many doctors do much, do so much extra work for free. I mean, name another profession where you work extra hours and aren't paid for it. Or you're doing your charts at night, not paid for it. Or on weekends, not paid for it. Or taking call nights and weekends, not paid for it. And I never understood that.
And it always bothered me immensely because I think physicians are amazing. We have so much to offer and we should be fairly compensated and respected for that. And that was one of the things that got me into wanting to transition.
And also my background as a counselor is really what got me interested in, and after I kind of got there, coaching other physicians on how they too can get there. what I do today, in addition to my utilization management job, is I also coach physicians. Specifically, I help people get remote careers, mostly in but I do know about other fields as well.
So you can always reach me at drjonathan.com or email me at drjonathan@drjonathan.com. Or please, as John mentioned, join our Facebook group of Remote Careers for Physicians, which is a wonderful community of physicians helping out physicians who are interested in remote careers. I always joke that I was into remote careers before being in a remote career was cool.
I started the Remote Careers Facebook group in 2018. And since the pandemic, it's exploded. Nowadays, everybody wants a remote career, it seems like. And I think it's as best of a time as any to transition into this field.
But I'm especially going to be talking about tonight, Utilization Management. what is Utilization Management? It's also called Utilization Review, but for tonight, we're going to call it UM or Utilization Management. the best definition I could find is it's a systematic approach used by health care organizations, insurance companies, and other stakeholders to evaluate and manage the appropriateness, efficiency, and cost effectiveness of health care services. the primary goal of UM is to ensure that patients receive the right care at the right time in the right setting, while minimizing unnecessary treatment costs and potential harm.
Another way I think about it is we reduce fraud, waste, and abuse, probably mostly waste. Probably 80% of what we deal with are waste, wasteful orders, or wasteful requests, etc., which we'll talk more about later. there's really three main buckets of UM companies.
And I always like to be very general about how I describe this, and then we'll move down into some specifics. there's private UM companies. These are those third-party companies that I always talk about, which are good companies to try to get experience with.
Those are superfluous. Many of them are listed in nairo.org, which we'll talk about later. Then there's health care systems, or hospital systems, which also hire UM nurses and UM doctors.
And then probably the most common for full-time docs would be insurance companies. insurance companies also hire their own UM nurses, their own UM doctors, their own UM physical therapists, pharmacists, etc. And these are the big names you've all heard of.
This is your Aetnas, your Humanas, your Uniteds, your Anthems, your Kaisers. They all hire their own UM clinicians to work for them. And what you do in UM is essentially usually one of three things.
There's prior authorizations. Everybody's heard about a prior auth. Everybody knows what a prior auth is. There's certainly a lot of attention in the news nowadays around prior auths and reducing the paperwork associated with prior authorizations. But there's a lot of UM that goes along with that. a physician orders a test, a study, a medication, a home health service, which I'm involved with.
And the prior auth physician determines whether or not that meets certain criteria, and most importantly, whether or not it is medically necessary. That's prior auth. And there's also concurrent reviews.
This is very common in the hospital setting. If when we're talking about bed days and how long a patient can stay in a hospital, how is this patient doing day to day? They're checking in to see if they can extend and give them more days or if they're suitable to go home or go to rehab or go to a different level of care.
That's called concurrent reviews. And then the final one is probably the smallest, and those are retrospective reviews. Those are done when the service has already been provided, already been rendered, and now they are reviewing it on the back end to see if it was medically necessary and if it fit the guidelines.
The reason why a lot of people go into UM is really primarily, I would say, what attracts people is the lifestyle, meaning it's typically remote. It's typically 40 hours a week when you're in a full-time gig. It's typically a salaried position, typically, not always. Also, you have very low liability. Basically, you're not practicing medicine. you don't need malpractice insurance.
You carry errors in admissions insurance. It's interesting work. It's a very comfortable pace, and you're not patient-facing. So it's a much lower, lower stress job. And you have typically, generally speaking, nights and weekends off and holidays off. In terms of compensation, and this is a very hot topic, I'm asked this all the time, there's really not good national average data. I will tell you what I see because I look at hundreds of positions for UM all the time. And I would say, and there's a very big range. I'm sorry, I can't be more specific.
But generally, if you're a full-time UM physician and you're in one of the primary care areas, you're typically talking about the lower to mid $200,000 range as a W-2 base salary. I've seen it all the way up to 300, maybe a little bit more for people like oncologists or people with very, very high demand skills. But keep in mind, in addition to that, first of all, that's 40 hours a week.
But in addition to that base salary, we're also talking about merit increases, which typically happen every year on the order of usually around 2% to 3%, but it can be more than that. In addition to that, you're talking about quarterly or annual bonuses. And you're also talking about usually a stock gift if you work at a large insurance company, as I do.
There's a lot of additional compensation that's also very attractive. always keep that in mind. I always like people to keep that in mind when they're saying, hey, but I make so much more money than that.
I say, yeah, but you probably work 80 hours a week and are 100 times more stressed. keep that in mind. Some other things I wanted to talk about is basically the process of what your typical day looks like when you're doing most UM.
And I'm going to talk about full-time jobs, and then we'll talk about the gigs. Okay, the full-time jobs, which are kind of the cream of the crop of which are those very, very highly desired 40-hour-a-week full-time jobs, which are very competitive, is you typically have a set number of cases that you're reviewing per day. There's nothing, you're not chained to your desk.
It's not like it is in most clinical practices where every second of your time is scheduled and monitored, and you need to be patient-facing in order to bill. No, I mean, you typically have a set number of cases that you're attempting to get through. Sometimes there's peer-to-peers involved as well.
And sometimes you have a few meetings and things like that when you're at the kind of the basic medical director level, medical director's entry level for utilization management. And then there are also opportunities to grow, kind of like Marie was talking about at MSL. There's some opportunities to grow into more of a team lead and manage a team.
And then there's opportunities for being a manager and managing a larger team, which that's what I do. I manage a large team of UM physicians, and I also hire them and interview them. And then there is also the opportunity to branch out into other fields in health insurance companies, which other people are talking about in their lectures tonight.
I won't get too much into that. something I do want to talk about is some of the other gigs in utilization management. there are small companies, usually these third-party companies that exist, and they do certain reviews.
They may be doing reviews for a certain procedure. They may be doing reviews for a certain medication. And what they'll do is they'll have a panel of doctors of 1099 or independent contractor physicians who they will reach out to and say, we have this request for this medication.
Can you review it for us? And we'll pay you X number of dollars. It's usually very low, by the way. It's usually like $20, $30. And those companies exist, and they are superfluous. And a lot of physicians look at that and say, I'm not doing that. And I say, you don't understand. You have to do that. You do that to get experience.
You don't do that to make money. You do it as a side gig while you're still in your other clinical job so that you can get some experience under your belt in doing UM so that you can put that on your CV. And that's why you do those roles for 6 to 12 months so that you can actually have some experience to talk about when you apply for those big full-time positions.
Now, how do you get these gigs? It's pretty simple. I talk about it all the time on remote careers. You just go to nairo.org, N-A-I-R-O, the National Association of Independent Review Organization, .org. You click on Members. Again, you don't become a member.
You click on Members, and you scroll all the way down, and it lists the logos of 20 or 30 of these companies. You go to every one of those individual company websites, and you navigate the website, and you click on Apply to be on the Physician Panel. And you submit your CV to every one of them.
I guarantee you at least two or three of them will contact you within the week and put you on their panel. And that means you are now getting UM experience. that's a great way to get UM experience. Yes, it does take a lot of time to sign up for all of them. I never said it would be easy. And it's a great way to get your first step in the door.
I always say this. My specialty is helping doctors who have no other experience, no outside experience, normal, average doctors. I guess no doctors average.
We're all awesome. But I would say regular doctors into the world of UM who have no prior or outside experience, no connections, nothing else. That's what I help people to do because that's how I got involved.
After you have that, the next thing that you need to do is after you've done that for six or 12 months, that's when you're able to actually apply to these full-time UM gigs that most people want. Like every other non-traditional job, especially nowadays, it is very competitive. However, what I can say, and I think this is really, really important, that it's not that it's super, super competitive, which it is, but it's more so the fact that doctors are used to it being ridiculously easy to get a job.
If you're a regular, traditional outpatient family doctor, been working at your clinic for 10 years, and now you want to move to a different city next week and you want a job there, all you have to do is send out an email with your CV to a couple people and you'll probably get 100 job offers the same week. That's how it is for clinical doctors. We're very spoiled, but that is not how it is when you make the transition.
That's something that you really have to psychologically get behind and understand that for many people, it's going to take a year, sometimes two years, to actually make that transition, to get enough applications in, to get rejected enough. As you always hear me on Facebook, for those who follow me, I always say to people, you haven't been rejected enough yet. That's your main problem.
It takes a lot of rejection, a lot of getting ghosted before you get your position, but you will get there. Don't worry, you will get there. It's just a process.
The thing that you also want to do is you want to work on your CV, and there's lots of coaches to help you with this. I'm one of them, but there's certainly many other coaches who can help you with this, many of whom you're hearing about these past three nights. You also want to work very hard on your interview skills, and coaches can help you with that.
I can certainly help, as can all the other coaches. What you want to do is you want to make it your job to, every day, apply and send in your CV to openings for utilization management. These are typically listed.
I like to keep things simple. They're typically listed on Indeed, on LinkedIn, and also on the private insurance company's websites. What I encourage people to do, who are interested in a life of is every single day, it only probably takes about an hour out of your day, you want to be visiting every one of those websites.
You want to be searching. You want to save this in your search. You want to be searching for medical director, utilization review, utilization management, utilization review physician, physician reviewer, MD reviewer, all those synonymous terms that a lot of companies use.
Then, you want to be looking for those positions, and you want to be submitting your CV. Yes, absolutely, networking is great. If you can do that, if you have any contacts, if you network through LinkedIn, if you network through one of these conferences, through a seat conference, for anything like that, that's wonderful.
What I can tell you is that in the UM world, things move very quickly. That works both in your favor and against your favor. Let me be more specific about timing. I always talk about, when I first got into about how I applied for a year and got rejected probably over a thousand times, at least hundreds and hundreds of times. I was rejected or ghosted. What I've learned now that I'm a hiring manager for UM is that timing is everything.
Let me be more specific on that. Many times, these UM companies, especially the insurance companies, which are the largest employer of UM docs, are always trying to get more business. They're always trying to get more contracts. They're always trying to expand their geography. They're always trying to do UM for another network, for another geographic location. They have business folks who, that's all they do, is try to broaden their business.
As you guys know, anybody who's worked in business, business is a tough field. Things move very fast and sometimes very unexpected. You can literally be at a job, or I can literally be in a position, and I can literally hear one day, hey, you know what? We finally got that contract we've been after for eight months or 12 months.
Now we have a need for five other doctors on your team, as we call them FTEs, full-time equivalents. Five FTEs on your team, and you need to get them up and trained and ready to go as soon as humanly possible, because we're going to start getting UM cases from that network in three months.
We got to be ready to go. This is the kind of thing that happens. What am I doing? We're posting it on our website, and the first good CV I get, who's board certified, who's got some decent experience, I am scheduling them for an interview. But let me tell you what, though. That same candidate, if they applied two weeks before, they probably would have gotten either ghosted or rejected.
Again, I don't write the rules, I'm just telling you what they are. The HR oasis for these big companies, don't assume that they're going to put your CV on hold. Don't assume that every job listed currently is available.
That's another one. Don't assume that you're going to even hear back. That's why my best advice is it's a numbers game. When the new positions come up, that's why you have to be checking every single day. You need to be applying for that new position, because that happens all the time in which is good news for people like us, because it means there are definitely jobs that open up and that need good folks. But the flip side of that, though, is let's say that you have 20 years of UM experience, 20 years of clinical experience.
You're the most competent UM doc in the world, and you reach out to me and send me your CV today. I'd say, I can't do anything with this, but thank you, because we don't have any openings. I'd say, just keep monitoring our website. That's how it works at a lot of the large health insurance companies. Yes, there's other things that happen at smaller companies where they may keep things on hold, but I'm just telling you how it works at the large health insurance companies. That's why I always say to people, and you see me say this on Facebook and everywhere else, apply, apply, apply.
And the clients that I work with, one of the biggest hurdles we have to get over is they fear rejection so much. I say, my gosh, I was rejected hundreds of times. I didn't even get to rejected status.
I was just ghosted. My application would just go into the big dark oasis, and nothing ever happened. And I just got over it.
And after a while, I started celebrating rejections, because every rejection is one step closer to an acceptance. And these jobs, especially UM jobs, as we were talking about, as Marie was talking about MSL jobs, they're very competitive. There's more docs than ever that are looking to make a transition.
The other thing is doctors are looking to make a transition earlier and earlier in their careers. My team, I would say, on a whole, at this point, we have about 25 docs on my team, and we are all stages of our career. There's people who are in their early career, mid-career, late career.
There's people who are post-retirement who just do this for fun, if that tells you anything about the job as well. it is difficult to get a position, but it's definitely not impossible. It just takes persistence.
And there's so many people who are there to help you. Let me talk a little bit about, I know there's a question on peer-to-peers. Let me talk a little bit about the ethics of utilization management.
Again, utilization management gets a bad rap sometimes for being, oh, we're just there to deny care and just to improve our profits. And nothing could be further from the truth. First of all, UM physicians do not get any sort of incentive, financial incentive, for denying patients.
That's illegal, and it does not exist. And especially the company I work for, which is a very ethical company, it just does not exist. I don't care one way or the other what decision a doctor makes.
It makes zero difference to me. All that I care about is that the quality of their review is very high, and the quality of their explanation is very thorough and very high, et cetera. what we do, so I work in the world of Medicare Advantage Utilization Management.
So we're working within the confines of what the Medicare Advantage Benefit provides. an example of this is a lot of people, a lot of doctors don't understand or don't know, and I don't blame them. They don't know sometimes what the benefits provide.
They don't know what the insurance benefit provides a patient. They may not know what the Medicare Advantage Plan benefit provides a patient. An example would be if somebody was ordering something that's not covered in the Medicare Advantage Benefit, something like custodial care or what we call unskilled home health aid support for a patient.
That is not something that the MA Benefit provides. CMS does not pay for that. It is not covered. That is not something I can authorize under any circumstances because it's not part of the benefit. that would be an example. If we were to do a peer-to-peer, what I would be saying to that physician is, hey, look, I know you ordered this, the home health aid for this patient, but are you aware that there's no, from what I can see at least, there's no other skilled need in the home.
They don't have a need for skilled nursing, for skilled physical therapy, occupational therapy, and CMS care is short-term and intermittent home care. I cannot authorize this because that's custodial and it's just not provided by the benefit. And I'm just very open about it.
And then what we do is we go out of our way to try to be of other service. I'll say, hey, have you considered maybe getting a social worker to help this member? Or perhaps I can get a case manager to help and see if there's other resources. Or maybe there's some local Medicaid resources we can help with. That's kind of that all or nothing. Now, then there are also peer-to-peers where, let me just start by saying this though.
When I do a peer-to-peer or anybody on my team does a peer-to-peer, there's a few reasons we're doing it. The biggest reason we're doing it is we want to make sure we have all the information that it's correct. That's why we're doing it.
We're not calling them up to just say, hey, too bad, sorry, so sad. I don't care what you have to say. Not at all.
We are physicians and those physicians in the field are our colleagues. They are not our patients. We have a great deal of respect for these treating physicians.
We have a great deal of respect for their thought processes. And what we're doing when we call is I want to know, make sure that I have all the information that it's correct. Nine times out of 10, the physician has additional information that's not in the documentation.
And we say, hey, thank you so much for letting me know that. I didn't know that this patient can only can only walk 10 feet. I thought it said 1,000 feet. I'm so sorry. I will change that right now. We'll be happy to approve those home PT visits for your patient.
That's what we're doing. The other thing is if we're making a decision, let's say we're granting four out of the requested eight home physical therapy visits, because our physical therapists and doctors, by the way, we also have all cases reviewed by PTs before they come to doctors, think that fewer are necessary. But I call up and the doctor tells me, yeah, but you have to understand that this member doesn't have a caregiver.
Nobody's helping them with their home exercise program. I don't know if that was in the documents, but I think they really need more cases like that. Absolutely. We are happy to do that.
Keep in mind that yes, there are some contentious spirit appears, but I would say, and I'm not making this up, that's less than, well less than 5%. Because generally these physicians they understand that we have a job to do and they're very happy that we're able to explain to them our thought processes is and why we're making these decisions.
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