Physician Advisor – Medical Reviewer, 1099 Contractor

This is a fully remote position, open to applicants in United States.

📋 Description

• Facilitate scheduled and on-demand peer-to-peer conversations with treating physicians and other qualified providers regarding requests for inpatient, outpatient, post-acute, and other authorizations.

• Assess members' clinical documentation, perform utilization management reviews, and evaluate relevant criteria and justifications for proposed or issued decisions.

• Analyze medical necessity and determine the suitable level of care, including inpatient versus observation/outpatient status.

• Implement CMS Medicare Advantage requirements, the Two-Midnight benchmark, applicable NCDs/LCDs, MCG or other sanctioned clinical criteria, and health plan policies.

• Discuss the clinical rationale for decisions with treating providers.

• Take into account additional clinical information and assess whether it impacts the medical necessity determination.

• Approve or reject proposed adverse determinations when new information supports such actions, in line with delegated authority and organizational policy.

• Refer complex, high-risk, or ambiguous cases to Medical Directors or clinical leadership.

• Accurately and promptly document P2P discussions.

• Complete P2P requests within the specified regulatory and organizational turnaround times.

• Identify recurring issues related to clinical, documentation, criteria, or provider education, and communicate trends to UM leadership.

• Collaborate with nurses, medical directors, appeals and grievances teams, provider engagement, and other operational units.

• Uphold confidentiality and adhere to HIPAA, CMS, accreditation, and organizational standards.

• Lead discussions on clinical JOCs during case reviews.

⛳️ Requirements

• MD or DO from a recognized medical school.

• Valid, unrestricted U.S. medical license.

• Board certification in a relevant clinical specialty; preference for Internal Medicine, Family Medicine, Emergency Medicine, or another specialty with extensive medical experience.

• Preferred minimum of 5 years of clinical practice experience.

• Strongly preferred experience in utilization management, medical necessity reviews, physician advisory services, payer medical reviews, or hospital case management.

• Preferred familiarity with Medicare Advantage and CMS medical necessity/coverage requirements.

• Familiarity with MCG, InterQual, CMS coverage policies, and the Two-Midnight rule is preferred.

• Strong communication skills for physician-to-physician interactions, with the ability to handle challenging or disputed clinical discussions professionally.

• Excellent clinical judgment.

• Expertise in medical necessity and level of care.

• Knowledge of Medicare/CMS requirements.

• Capability for timely decision-making.

• Proficiency in accurate clinical documentation.

• Professional conflict resolution skills.

• Consistent application of clinical criteria and policy.

• Ability to differentiate clinical medical-necessity decisions from contractual or administrative matters.

🏝️ Benefits

• Comprehensive health, dental, and vision insurance.

• Retirement plan with employer match.

• Generous paid time off and holidays.

• Continuing education reimbursement.

• Flexible work schedule options.