Physician Advisor – Peer-to-Peer Medical Reviewer

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

📋 Description

• Facilitate both scheduled and impromptu peer-to-peer dialogues with treating physicians and other qualified providers concerning inpatient, outpatient, post-acute, and various authorization requests.

• Review member clinical documentation, conduct utilization management evaluations, and assess relevant criteria and justifications prior to peer-to-peer conversations.

• Assess the medical necessity and level of care, distinguishing between inpatient and observation/outpatient statuses.

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

• Engage in professional discussions regarding clinical rationales with treating providers.

• Take into account new clinical data and modify medical necessity judgments or reverse proposed adverse decisions when justified and within delegated authority.

• Diligently document peer-to-peer interactions, clinical specifics, involved parties, outcomes, and reasoning within mandated regulatory and organizational timelines.

• Elevate complex, high-risk, or ambiguous cases to Medical Directors or clinical leadership for further assessment.

• Lead clinical case review discussions within Joint Operating Committees.

• Identify recurring trends in clinical, documentation, or provider-education opportunities and relay these insights to utilization management leadership.

⛳️ Requirements

• MD or DO degree from a recognized medical school.

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

• Board certification in a relevant clinical specialty is preferred, such as Internal Medicine, Family Medicine, Emergency Medicine, or another specialty with extensive medical experience.

• Preferred 5+ years of clinical practice experience.

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

• High level of familiarity with Medicare Advantage, CMS coverage requirements, MCG, InterQual, NCD/LCD criteria, and the Two-Midnight rule.

• Outstanding physician-to-physician communication abilities.

• Competence in handling challenging or contentious clinical discussions in a professional manner.

• Capability to make informed medical necessity determinations.

• Skill in differentiating clinical decisions from administrative or contractual matters.

• Strict adherence to HIPAA regulations.

🏝️ Benefits

• Remote work arrangement.