Physician Advisor- Peer-to-Peer Medical Reviewer

• 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.