Physician Advisor- Peer-to-Peer Medical Reviewer
# Physician Advisor- Peer-to-Peer Medical Reviewer **HJ Staffing** · United States · `Remote` · `Full Time` 💼 **Уровень роли:** `Senior` 🕒 **Статус:** *Опубликовано: сегодня* · *Источник: Himalayas (JSON API)* --- ### Top Skills & Match 🎯 **Ключевой стек роли:** `[Physician-Advisor]` `[Medical-Reviewer]` `[Utilization-Management-Physician]` `[Peer-Review-Associate]` `[Physician-Reviewer]` `[Peer-Review-Physician]` `[Medical-Peer-Reviewer]` `[Physician-Peer-Review]` `[Physician-Medical-Advisor]` `[Medical-Advisory-Reviewer]` `[Medical-Review-Physician]` `[Board-Certified-Physician-Reviewer]` `[Medical-Review-Consultant]` --- ### About the Role HJ STAFFING is seeking two (2) experienced, detail-oriented Physician Advisors – Peer-to-Peer (P2P) Medical Reviewers to conduct clinical discussions with treating providers regarding utilization management determinations. In this role, you will apply Medicare/CMS requirements, applicable medical necessity criteria, health plan policies, and clinical judgment to determine the appropriate level of care and/or medical necessity of requested services. You will support timely, consistent, evidence-based utilization management while providing treating physicians the opportunity to discuss relevant clinical information before or following an adverse determination, as applicable. What You Will Do - Conduct Peer-to-Peer Reviews: Lead scheduled and ad hoc P2P discussions with treating physicians and other qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests. - Review & Evaluate Cases: Analyze member clinical documentation, utilization management reviews, applicable criteria, and rationale prior to P2P discussions. Evaluate medical necessity and level of care (inpatient vs. observation/outpatient status). - Apply Regulatory & Clinical Criteria: Utilize CMS Medicare Advantage requirements, the Two-Midnight benchmark, NCDs/LCDs, MCG or other approved clinical criteria, and health plan policies. - Engage & Collaborate Collegially: Discuss clinical rationales professionally with treating providers. Consider new clinical information during P2P discussions and adjust medical necessity determinations or overturn proposed adverse determinations when supported, within delegated authority. - Documentation & Compliance: Accurately and contemporaneously document P2P discussions, clinical details, participants, outcomes, and rationale within required regulatory and organizational turnaround times. Maintain strict HIPAA compliance. - Escalation & Leadership: Escalate complex, high-risk, or unclear cases to Medical Directors or clinical leadership. Lead case review discussions on clinical Joint Operating Committees (JOCs). - Identify Trends: Spot recurring clinical, documentation, or provider-education opportunities and communicate trends to utilization management leadership. What You Will Bring - Degree: MD or DO from an accredited medical school. - Licensure: Active, current, and unrestricted U.S. medical license. - Board Certification: Board certification in an appropriate clinical specialty (Internal Medicine, Family Medicine, Emergency Medicine, or another specialty with broad medical experience is preferred). - Clinical Experience: 5+ years of clinical practice experience is preferred. - Utilization Management Experience: Prior experience in utilization management, medical necessity review, physician advisory services, payer medical review, or hospital case management is strongly preferred. - Regulatory & Criteria Knowledge: Strong familiarity with Medicare Advantage, CMS coverage requirements, MCG, InterQual, NCD/LCD criteria, and the Two-Midnight rule. - Communication & Judgment: Exceptional physician-to-physician communication skills, with the ability to professionally navigate difficult or disputed clinical discussions, make sound medical necessity determinations, and distinguish clinical decisions from administrative/contractual issues. Originally posted on Himalayas
- Physician-Advisor
- Medical-Reviewer
- Utilization-Management-Physician
- Peer-Review-Associate
- Physician-Reviewer
- Peer-Review-Physician
- Medical-Peer-Reviewer
- Physician-Peer-Review
- Physician-Medical-Advisor
- Medical-Advisory-Reviewer
- Medical-Review-Physician
- Board-Certified-Physician-Reviewer
- Medical-Review-Consultant
Наблюдалась 2026-09-30, впервые 2026-09-30, источник — Himalayas (JSON API).