Medical Evaluator

Company DescriptionVIP Universal Medical Insurance Group (VUMI®) is an international health insurance organization offering major medical insurance products and specialized VIP medical services to individuals and corporations worldwide. VUMI provides a wide variety of health plans, including access to features such as Second Medical Opinion VIP®, global telemedicine, and at-home doctor visits. With offices across the United States, Canada, the United Arab Emirates, Latin America, and Europe, VUMI operates as part of a global healthcare management group with over 40 years of industry experience. The company employs more than 590 professionals of diverse nationalities, ensuring comprehensive global expertise and service.
Availability to work rotating on-call shifts, including weekday on-call coverage from 5:00 PM to 9:00 AM, and 24-hour weekend on-call shifts based on a rotating schedule.
Medical Evaluator
About the RoleWe are seeking an experienced Medical Evaluator to join our International Health team. In this role, you will be responsible for reviewing and making clinical decisions on Level 1 pre-authorizations, overseeing the medical necessity of ongoing hospitalizations, supporting high-cost case management, and serving as the clinical reference for Medical Coordinators.This position requires strong clinical judgment, expertise in utilization management, and the ability to balance evidence-based medicine, policy provisions, and exceptional member care. The Medical Evaluator may also participate in an After-Hours Deputy Clinical Officer (ADCO) on-call rotation.
Key ResponsibilitiesReview and evaluate Level 1 medical pre-authorizations, ensuring medical necessity and compliance with policy benefits and clinical guidelines.Apply internationally recognized utilization management criteria (Milliman, InterQual, or equivalent) to support authorization decisions.Approve, deny, or modify treatment plans based on clinical evidence, policy provisions, and utilization review standards.Review hospital admissions, level of care, and length-of-stay extensions to ensure ongoing medical necessity.Monitor high-cost and complex cases, providing clinical oversight throughout the member's treatment journey.Support discharge planning and continuity of care by collaborating with treating providers and internal teams.Present assigned cases during the Case Management Committee (CMC) and execute agreed action plans.Provide clinical guidance to Medical Coordinators, Claims teams, and other internal stakeholders.Conduct peer-to-peer discussions with treating physicians when additional clinical clarification is required.Ensure all clinical decisions are accurately documented and compliant with regulatory, contractual, and internal governance requirements.Promote cost-effective treatment alternatives while maintaining patient safety and quality of care.Identify potential fraud, waste, abuse, or inappropriate utilization and escalate findings according to company procedures.Participate in quality assurance initiatives, clinical audits, process improvements, and the development of internal clinical guidelines.Participate in the ADCO after-hours rotation, providing clinical support for urgent escalations and emergency authorizations when required.
QualificationsMedical Doctor (MD) degree required. Specialization in Internal Medicine, Emergency Medicine, Public Health, Clinical Management, or a related specialty is preferred.Minimum of 3–5 years of experience in Medical Management, Case Management, Utilization Review, or Clinical Evaluation within an international health insurance company or healthcare organization.Strong knowledge of international medical necessity guidelines, including Milliman Clinical Guidelines, InterQual, or equivalent utilization review tools.In-depth understanding of international health insurance policies, including benefits, exclusions, deductibles, coinsurance, and coverage limits.Experience determining the appropriate Level of Care (LOC) and managing hospital length-of-stay reviews.Ability to conduct peer-to-peer clinical reviews with treating physicians using evidence-based medical criteria.Advanced English proficiency (written and verbal), with the ability to document clinical decisions accurately and professionally.Experience using Case Management, Clinical Management, and Utilization Review systems.Knowledge of healthcare regulations and medical governance frameworks applicable to Latin America and the United States/Canada.Portuguese language is a plus.