Physician Advisor- Peer-to-Peer Medical Reviewer

HJSRLLC; United States; On-site; USD 150,000 - 190,000; Full time

Job summary

HJ STAFFING seeks two experienced Physician Advisors – Peer-to-Peer (P2P) Medical Reviewers to conduct clinical discussions with treating providers regarding utilization management determinations.

In this role 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.

Responsibilities

• Lead scheduled and ad hoc Peer-to-Peer discussions with treating physicians and other qualified providers regarding utilization requests.
• Analyze member clinical documentation and rationale prior to P2P discussions; evaluate medical necessity and level of care.
• Utilize CMS Medicare Advantage requirements, the Two-Midnight rule, NCDs/LCDs, MCG or other approved clinical criteria, and health plan policies.
• Discuss clinical rationales professionally with treating providers and adjust determinations when supported.
• Accurately document P2P discussions, clinical details, participants, outcomes, and rationale within regulatory timelines, maintaining HIPAA compliance.
• Escalate complex or high-risk cases to Medical Directors; lead case review discussions in JOCs.
• Identify trends and opportunities for provider education and communicate with utilization management leadership.

Skills

P2P communications

Clinical judgment

CMS knowledge

HIPAA compliance

Education

MD or DO from an accredited medical school

Job description

HJ STAFFING is seeking two (2) experienced, detail-oriented Physician Advisors – Peer-to-Peer (P2P) Medical Reviewers to conduct clinical discussions with treating providers regarding utilization management determinations.

In this role, 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. You will support timely, consistent, evidence-based utilization management while providing treating physicians the opportunity to discuss relevant clinical information before or following an adverse determination, as applicable.

What You Will Do

• Conduct Peer-to-Peer Reviews: Lead scheduled and ad hoc P2P discussions with treating physicians and other qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests.
• Review & Evaluate Cases: Analyze member clinical documentation, utilization management reviews, applicable criteria, and rationale prior to P2P discussions. Evaluate medical necessity and level of care (inpatient vs. observation/outpatient status).
• Apply Regulatory & Clinical Criteria: Utilize CMS Medicare Advantage requirements, the Two-Midnight benchmark, NCDs/LCDs, MCG or other approved clinical criteria, and health plan policies.
• Engage & Collaborate Collegially: Discuss clinical rationales professionally with treating providers. Consider new clinical information during P2P discussions and adjust medical necessity determinations or overturn proposed adverse determinations when supported, within delegated authority.
• Documentation & Compliance: Accurately and contemporaneously document P2P discussions, clinical details, participants, outcomes, and rationale within required regulatory and organizational turnaround times. Maintain strict HIPAA compliance.
• Escalation & Leadership: Escalate complex, high-risk, or unclear cases to Medical Directors or clinical leadership. Lead case review discussions on clinical Joint Operating Committees (JOCs).
• Identify Trends: Spot recurring clinical, documentation, or provider-education opportunities and communicate trends to utilization management leadership.

What You Will Bring

• Degree: MD or DO from an accredited medical school.
• Licensure: Active, current, and unrestricted U.S. medical license.
• Board Certification: Board certification in an appropriate clinical specialty (Internal Medicine, Family Medicine, Emergency Medicine, or another specialty with broad medical experience is preferred).
• Clinical Experience: 5+ years of clinical practice experience is preferred.
• Utilization Management Experience: Prior experience in utilization management, medical necessity review, physician advisory services, payer medical review, or hospital case management is strongly preferred.
• Regulatory & Criteria Knowledge: Strong familiarity with Medicare Advantage, CMS coverage requirements, MCG, InterQual, NCD/LCD criteria, and the Two-Midnight rule.
• Communication & Judgment: Exceptional physician-to-physician communication skills, with the ability to professionally navigate difficult or disputed clinical discussions, make sound medical necessity determinations, and distinguish clinical decisions from administrative/contractual issues.