Physician Advisor: Peer-to-Peer Medical Reviewer

HJSRLLC; Eagan (MN); On-site; USD 170,000 - 210,000; Full time

Job summary

HJ STAFFING is seeking two experienced Physician Advisors – Peer-to-Peer Medical Reviewers to conduct clinical discussions with treating providers regarding utilization management determinations.

You will apply Medicare/CMS requirements, applicable medical necessity criteria, health plan policies, and clinical judgment to determine the appropriate level of care and/or medical necessity of requested services.

Qualifications

• MD or DO from an accredited medical school.
• Active, current, and unrestricted U.S. medical license.
• Board certification in Internal Medicine, Family Medicine, Emergency Medicine, or another broad specialty.
• 5+ years of clinical practice experience preferred.
• Prior utilization management or payer medical review experience preferred.
• Strong familiarity with Medicare Advantage, CMS coverage requirements, MCG/InterQual, NCDs/LCD criteria, and the Two-Midnight rule.
• Exceptional physician-to-physician communication skills and the ability to navigate challenging clinical discussions.

Responsibilities

• Lead scheduled and ad hoc Peer-to-Peer discussions with treating physicians regarding inpatient, outpatient, post-acute, and authorization requests.
• Analyze member clinical documentation and utilization management reviews prior to P2P discussions; evaluate medical necessity and level of care.
• Apply CMS Medicare Advantage requirements, the Two-Midnight benchmark, NCDs/LCDs, MCG or other criteria, and health plan policies.
• Discuss clinical rationales professionally with treating providers and adjust determinations when supported.
• Document P2P discussions, clinical details, participants, outcomes, and rationale timely and HIPAA-compliant.
• Escalate complex cases to Medical Directors; lead case review discussions in Joint Operating Committees.
• Identify trends and communicate opportunities to utilization management leadership.

Skills

MD/DO

Medical license

Board certification

Clinical experience

Utilization management

Regulatory knowledge

Communication

Education

MD or DO

Job description

HJ STAFFING is seeking two experienced Physician Advisors – Peer-to-Peer Medical Reviewers to conduct clinical discussions with treating providers regarding utilization management determinations.

You will apply Medicare/CMS requirements, applicable medical necessity criteria, health plan policies, and clinical judgment to determine the appropriate level of care and/or medical necessity of requested services.