Peer-to-Peer (P2P) Review RN - R1 RCM

R1 RCM, Inc.; Hyderabad; Sur place; INR 900 000 - 1 300 000; Plein temps

Résumé du poste

R1 RCM, Inc. is seeking a Peer-to-Peer (P2P) Review RN to support Physician Advisors by reviewing clinically complex cases denied by payers.

You will analyze medical records, apply evidence-based criteria and prepare concise medical-necessity arguments for payer discussions. In this on-site Hyderabad role, you collaborate with UR nurses, case managers and physicians, track review status, and ensure quality, productivity and turnaround targets while maintaining strict adherence to Medicare and

Qualifications

• Active US RN license (NCLEX) or MBBS qualification.
• 3+ years clinical nursing experience (preferred).
• 2+ years of recent acute-care Utilization Review experience (good to have).
• Knowledge of Medicare and payer medical-necessity requirements.
• Strong clinical abstraction, analytical, documentation, and communication skills.
• Ability to work independently in a fast-paced environment.

Responsabilités

• Review clinical records including ED notes, H&P, progress notes, labs, imaging, vital trends, therapy notes, and medication records.
• Evaluate medical necessities using InterQual, MCG, payer-specific criteria, and clinical judgment.
• Prepare clear, evidence-based clinical summaries supporting the requested level of care or authorization.
• Identify documentation strengths, gaps, and potential risks before physician review.
• Provide Physician Advisors with organized clinical evidence to support payer discussions.
• Track review status, payer requests, approvals, denials, and follow-up requirements.
• Collaborate with UR nurses, case managers, physicians, and other stakeholders.
• Meet established quality, productivity, compliance, and turnaround requirements.
• Provide feedback on recurring issues and root causes contributing to case determinations.

Connaissances

Clinical nursing experience

Analytical skills

Documentation skills

Communication skills

Independence

Formation

US Registered Nurse license (NCLEX)

MBBS Physicians

Description du poste

Job Summary:

The Peer-to-Peer (P2P) Review RN supports Physician Advisors by reviewing clinically complex cases challenged or denied by payers. The RN analyzes medical records, applies evidence-based criteria, identifies documentation gaps, and develops concise medical-necessity arguments to prepare physicians for payer peer-to-peer discussions.

Key Responsibilities:

• Review clinical records including ED notes, H&P, progress notes, labs, imaging, vital trends, therapy notes, and medication records.
• Evaluate medical necessities using InterQual, MCG, payer-specific criteria, and clinical judgment.
• Prepare clear, evidence-based clinical summaries supporting the requested level of care or authorization.
• Identify documentation strengths, gaps, and potential risks before physician review.
• Provide Physician Advisors with organized clinical evidence to support payer discussions.
• Track review status, payer requests, approvals, denials, and follow-up requirements.
• Collaborate with UR nurses, case managers, physicians, and other stakeholders.
• Meet established quality, productivity, compliance, and turnaround requirements.
• Provide feedback on recurring issues and root causes contributing to case determinations.

Required Qualifications:

• Active US Registered Nurse license (NCLEX certification), or
• MBBS Physicians.
• 3+ years clinical nursing experience (preferred, not mandate)
• 2+ years of recent acute-care Utilization Review experience (Good to have)
• Knowledge of Medicare and payer medical-necessity requirements.
• Strong clinical abstraction, analytical, documentation, and communication skills.
• Ability to work independently in a fast-paced environment

Preferred, not mandate:

• CCM or ACM certification.
• Experience with concurrent denials, medical-necessity reviews, or P2P case preparation.
• Strong knowledge across multiple clinical specialties.

Contact Person: Kotha Maheshwari - Lead Associate

Contact Number: 6309134613