Medical Evaluator

About the role

We are looking for an experienced Medical Evaluator to join our International Health team. You will review Level 1 pre‑authorizations, oversee medical necessity for hospital stays, and support high‑cost case management while serving as a clinical reference for Medical Coordinators.

Key responsibilities

• Review and evaluate Level 1 medical pre‑authorizations for necessity and policy compliance.
• Apply utilization management criteria (Milliman, InterQual, or equivalent) to make authorization decisions.
• Approve, deny, or modify treatment plans based on clinical evidence and policy provisions.
• Assess hospital admissions, level of care, and length‑of‑stay extensions.
• Monitor high‑cost and complex cases, providing clinical oversight throughout treatment.
• Support discharge planning and continuity of care in collaboration with providers and internal teams.
• Present cases to the Case Management Committee and execute agreed action plans.
• Provide clinical guidance to Medical Coordinators, Claims teams, and other stakeholders.
• Conduct peer‑to‑peer discussions with treating physicians when clarification is needed.
• Document all clinical decisions in compliance with regulatory and internal governance.
• Identify and escalate potential fraud, waste, abuse, or inappropriate utilization.

Required profile

• Proven experience in utilization management and clinical decision‑making.
• Strong knowledge of evidence‑based medicine and health‑insurance policy.
• Ability to balance clinical guidelines with member‑centric care.
• Excellent communication skills for peer‑to‑peer discussions and committee presentations.

Required skills

• Utilization Management
• Milliman criteria
• InterQual criteria

What we offer

• Opportunity to work within a global health‑insurance organization.
• Rotating on‑call schedule with after‑hours clinical responsibilities.
• Collaboration with a diverse, international team of professionals.