Physician Reviewer- REMOTE

Sierra Solutions; Boston (MA); Remote; USD 236,000 - 354,000; Full time

Job summary

A leading health care organization is seeking a board-certified physician with experience in managed care to perform peer-to-peer reviews and assess medical necessity. Responsibilities include interpreting health plan policies, documenting clinical determinations, and collaborating with interdisciplinary teams. The ideal candidate will have a strong background in clinical settings, excellent communication skills, and a comprehensive understanding of regulatory standards to ensure compliance. Join us in supporting evidence-based care and enhancing patient outcomes.

Qualifications

• Minimum of 3-5 years of clinical experience, preferably in managed care.
• Prior experience with appeals, grievances, or peer review is highly desirable.

Responsibilities

• Conduct medical necessity reviews for appeals and peer consultations.
• Document clinical determinations and rationale clearly.
• Collaborate with internal teams including case managers and compliance staff.

Skills

Clinical documentation skills

Excellent communication

Knowledge of regulatory standards

Education

MD or DO degree from an accredited medical school

Board certification in a medical specialty

Current, unrestricted medical license in the United States

Job description

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Job Summary
We are seeking a board-certified physician (MD or DO) with clinical experience and knowledge of managed care processes to conduct peer-to-peer reviews, and review appeals and grievances for medical necessity, appropriateness of care, and compliance with health plan policies. The ideal candidate will ensure clinical decisions support evidence-based care and regulatory guidelines.

Primary Responsibilities

• Conduct medical necessity reviews for appeals, grievances, and peer-to-peer consultations.
• Interpret and apply health plan policies, clinical guidelines, and regulatory requirements.
• Communicate directly with requesting providers during peer-to-peer discussions.
• Document clinical determinations and rationale clearly and concisely.
• Collaborate with internal teams including case managers, utilization review nurses, and compliance staff.
• Participate in committee meetings, audits, and quality improvement initiatives as needed.

Education and Experience

• MD or DO degree from an accredited medical school.
• Current, unrestricted medical license in the United States.
• Board certification in a medical specialty.
• Minimum of 3-5 years of clinical experience, preferably with experience in managed care or utilization management.
• Prior experience with appeals, grievances, or peer review is highly desirable.
• Excellent communication and clinical documentation skills.
• Knowledge of regulatory standards (CMS, NCQA, URAC, etc.).

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Contract

Job function

• Job function

  Health Care Provider

• Industries

  Hospitals and Health Care

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