Job Description

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Physician Advisor- Peer-to-Peer Medical Reviewer based in United States. As a Physician Advisor – Peer-to-Peer Medical Reviewer, you will conduct clinical discussions with treating providers regarding utilization management determinations and requested services. You will review clinical documentation, assess medical necessity, and determine appropriate levels of care using evidence-based criteria and applicable regulatory requirements. The role involves direct physician-to-physician communication and requires sound clinical judgment when evaluating complex or disputed cases. You will apply Medicare Advantage and CMS requirements alongside established utilization management guidelines and health plan policies. You will also contribute to timely, consistent, and compliant case decisions while identifying opportunities for provider education and process improvement. This full-time remote opportunity is designed for an experienced physician comfortable working collaboratively across clinical and utilization management environments. 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.

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