Physician Advisor – Peer-to-Peer Medical Reviewer
New
J
JobgetherUtilization management
Remote; based in United StatesFull-TimeSenior
Salary not disclosed
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Job Details
- Experience
- 5+ years of clinical practice experience preferred.
Requirements
- Hold an MD or DO degree from an accredited medical school.
- Maintain an active, current, and unrestricted U.S. medical license.
- Be board certified in an appropriate clinical specialty; Internal Medicine, Family Medicine, Emergency Medicine, or another specialty with broad medical experience is preferred.
- Have 5+ years of clinical practice experience preferred.
- Prior experience in utilization management, medical necessity review, physician advisory services, payer medical review, or hospital case management is strongly preferred.
- Have strong knowledge of Medicare Advantage and CMS coverage requirements.
- Be familiar with MCG, InterQual, NCD/LCD criteria, and the Two-Midnight rule.
- Demonstrate physician-to-physician communication skills and the ability to navigate difficult or disputed clinical discussions professionally.
- Apply sound clinical judgment to medical necessity determinations and distinguish clinical decisions from administrative or contractual considerations.
- Maintain attention to detail, documentation, compliance, and timely case management.
Responsibilities
- Conduct scheduled and ad hoc peer-to-peer discussions with treating physicians and qualified providers about authorization requests.
- Review member clinical documentation, utilization management assessments, applicable criteria, and case rationale before discussions.
- Evaluate medical necessity and determine the appropriate level of care, including inpatient versus observation or outpatient status.
- Apply Medicare Advantage and CMS requirements, the Two-Midnight benchmark, NCDs, LCDs, MCG or other approved clinical criteria, and health plan policies.
- Consider new clinical information during discussions and adjust or overturn proposed adverse determinations when supported and within delegated authority.
- Document discussions, clinical information, participants, outcomes, and rationale within required turnaround times.
- Escalate complex, high-risk, or unclear cases to Medical Directors or appropriate clinical leadership.
- Lead case review discussions during clinical Joint Operating Committees as needed.
- Identify recurring clinical, documentation, or provider-education trends and communicate opportunities to utilization management leadership.
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