Utilization Review Physician-Remote Expert

Timothy Ziolkowski, MD

Board-Certified Emergency Medicine Physician

Utilization Review Physician Physician Reviewer Former Reviewing Medical Director (Humana)

Corbin, KY

KY TN WV Licensed DEA Active

606-***-**** ************@*******.***

PROFESSIONAL SUMMARY

Board-Certified Emergency Medicine physician with payer-side leadership experience as Reviewing Medical Director at Humana and extensive experience in high-volume utilization review, prior authorization, and appeals determination for Medicare, Medicaid, and commercial populations.

Expert in evidence-based medical necessity review, peer-to-peer consultation, and defensible documentation aligned with CMS and payer policies. Proven ability to deliver efficient, consistent, audit-ready determinations in fully remote environments.

Actively seeking 1099 contract roles in utilization review, physician advisory, and independent medical review.

CORE COMPETENCIES

Utilization Review (UR) Medical Necessity Determinations Prior Authorization

Peer-to-Peer Review Appeals & Denials Independent Physician Review

CMS & Payer Policy Compliance InterQual / MCG Guidelines

Clinical Documentation Review Audit-Ready Reporting

Remote Review Workflow High-Volume Case Throughput

PROFESSIONAL EXPERIENCE

Reviewing Medical Director – Humana (Southeast Region)

Aug 2025 – Feb 2026

Performed high-volume utilization review and medical necessity determinations across inpatient and outpatient services

Applied InterQual/MCG criteria and payer-specific policies to authorization decisions

Conducted peer-to-peer consultations to resolve authorization and denial cases

Produced clear, defensible documentation supporting approvals and denials

Participated in appeals, reconsiderations, and complex case reviews

Maintained compliance with CMS, Medicare Advantage, and Medicaid regulations

Emergency Medicine Physician (Leadership & Staff Roles)

Multiple Health Systems 2006 – 2025

Delivered care in high-acuity, high-volume clinical environments

Developed expertise in rapid clinical decision-making and risk stratification

Served in leadership roles including Facility Medical Director, Associate Medical Director, Chest Pain Center Director, Stroke Center Director

Led accreditation and quality improvement initiatives

Participated in peer review, utilization review, and clinical documentation improvement

MILITARY SERVICE

U.S. Navy (1996–2004)

Command Airwing Flight Surgeon (CVW-1)

Station Command Flight Surgeon (NAS-JRB, Fort Worth)

Navy Commendation Medal (Gold Star)

EDUCATION & CERTIFICATION

Diplomate, American Board of Emergency Medicine

Emergency Medicine Residency – University of Louisville

MD – University of Texas Health Science Center at Houston

BS Pharmacy (Honors) – University of Texas at Austin

LICENSURE

Kentucky #39137 (Active, Unrestricted)

Tennessee #54323 (Active)

West Virginia #27164 (Active)

DEA: Active (multi-state)

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