Physician Advisor- Peer-to-Peer Medical Reviewer

Accountabilities: • Conduct scheduled and ad hoc peer-to-peer discussions with treating physicians and qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests.

• Review member clinical documentation, utilization management assessments, applicable criteria, and case rationale before peer-to-peer 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 applicable health plan policies.

• Engage professionally with treating providers, consider new clinical information presented during discussions, and adjust or overturn proposed adverse determinations when supported and within delegated authority.

• Accurately document peer-to-peer discussions, clinical information, participants, outcomes, and rationale within required regulatory and organizational turnaround times.

• Maintain strict compliance with HIPAA and applicable clinical and regulatory requirements.

• Escalate complex, high-risk, or unclear cases to Medical Directors or appropriate clinical leadership.

• Lead case review discussions during clinical Joint Operating Committees (JOCs) as needed.

• Identify recurring clinical, documentation, or provider-education trends and communicate relevant opportunities to utilization management leadership.

Requirements:

• MD or DO degree from an accredited medical school.

• Active, current, and unrestricted U.S. medical license.

• Board certification in an appropriate clinical specialty; Internal Medicine, Family Medicine, Emergency Medicine, or another specialty with broad medical experience is preferred.

• 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.

• Strong knowledge of Medicare Advantage and CMS coverage requirements.

• Familiarity with MCG, InterQual, NCD/LCD criteria, and the Two-Midnight rule.

• Exceptional physician-to-physician communication skills and the ability to navigate difficult or disputed clinical discussions professionally.

• Strong clinical judgment and the ability to make sound medical necessity determinations.

• Ability to distinguish clinical decisions from administrative or contractual considerations.

• Strong attention to detail, documentation, compliance, and timely case management.

• Ability to collaborate effectively with clinical leadership, treating providers, and utilization management teams.

Benefits:

• Full-time position.

• Remote work arrangement.

• Opportunity to perform meaningful physician-to-physician clinical review and utilization management work.

• Direct involvement in medical necessity and level-of-care determinations.

• Exposure to Medicare Advantage, CMS requirements, clinical criteria, and health plan utilization management processes.

• Opportunity to collaborate with treating providers, Medical Directors, clinical leadership, and utilization management teams.

• Opportunities to contribute to clinical Joint Operating Committees and provider-education initiatives.

• Specific salary, healthcare, retirement, paid time off, and additional benefits were not specified in the source job description.

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