Physician Advisor – Peer-to-Peer Medical Reviewer

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

📋 Description

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

• Review member clinical documentation, utilization management assessments, relevant criteria, and rationales prior to peer-to-peer discussions.

• Assess medical necessity and levels of care, including differentiating between inpatient and observation/outpatient status.

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

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

• Take into account new clinical information and modify medical necessity determinations or reverse proposed adverse decisions when evidence supports such actions and falls within delegated authority.

• Record peer-to-peer discussions, clinical particulars, participants, outcomes, and rationales within mandated regulatory and organizational timelines.

• Uphold stringent HIPAA compliance.

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

• Direct case review discussions within clinical Joint Operating Committees.

• Recognize recurring clinical, documentation, or provider-education opportunities and relay trends to utilization management leadership.

⛳️ Requirements

• MD or DO degree from a recognized medical institution.

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

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

• A minimum of 5 years of clinical practice experience is preferred.

• Previous experience in utilization management, medical necessity evaluations, physician advisory services, payer medical reviews, or hospital case management is strongly preferred.

• Strong knowledge of Medicare Advantage, CMS coverage requirements, MCG, InterQual, NCD/LCD criteria, and the Two-Midnight rule.

• Outstanding physician-to-physician communication abilities.

• Capability to navigate challenging or contested clinical discussions in a professional manner.

• Aptitude for making sound medical necessity assessments.

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

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional development and training.

• Supportive and collaborative work environment.

• Flexible work arrangements available.