Specialist / Senior Specialist

R1 RCM, Inc.; Hyderabad; On-site; INR 2,250,000 - 2,750,000; Full time

Job summary

R1RCM, Inc. in Hyderabad is seeking Specialists for Peer-to-Peer Review to support Physician Advisors by reviewing complex payer-denied cases. RN/Physician analyzes medical records and develops concise medical-necessity arguments for payer peer-to-peer discussions.

Responsibilities include evaluating records, using criteria like InterQual/MCG, and preparing evidence-based summaries to justify care level approvals. Collaboration with UR nurses and physicians is essential.

Qualifications

• MBBS physicians or active US RN license (NCLEX) required.
• Minimum 3+ years clinical nursing experience preferred.
• 2+ years recent acute-care Utilization Review experience desirable.

Responsibilities

• Review clinical records (ED notes, H&P, progress notes, labs, imaging, meds).
• Evaluate medical necessity using InterQual, MCG, payer criteria.
• Prepare clear, evidence-based clinical summaries for level of care/authorization.
• Identify documentation gaps and risks before physician review.
• Provide organized clinical evidence to support payer discussions.
• Track review status, payer requests, approvals, denials, follow-ups.
• Collaborate with UR nurses, case managers, physicians, and stakeholders.
• Meet quality, productivity, compliance, and turnaround targets.
• Provide feedback on recurring issues and root causes of determinations.

Skills

Analytical skills

Documentation skills

Communication skills

Independent work

Education

MBBS physicians

US RN license (NCLEX)

Job description

Greetings from R1RCM,

We're hiring for Specialist / Senior Specialist.

Job Location : Hyderabad

Qualification : MBBS Physicians or active US Registered Nurse license (NCLEX certification)

Salary : Up-to 25 LPA

Job Description: Peer-to-Peer Review

Job Summary

The Peer-to-Peer (P2P) Review supports Physician Advisors by reviewing clinically complex cases challenged or denied by payers. The RN/Physician 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 necessity 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

• MBBS Physicians or active US Registered Nurse license (NCLEX certification)
• 3+ years clinical nursing experience (preferred, not mandate)
• 2+ years 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

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