Physician Reviewer- REMOTE

Sierra Solutions Group; Boston (MA); Remote; USD 200,000 - 250,000; Full time

Job summary

Une entreprise de santé dynamique recherche un médecin certifié (MD ou DO) pour des évaluations de nécessité médicale et des discussions éventuelles avec des prestataires. Le candidat idéal doit avoir une expérience clinique solide et une connaissance des processus de gestion des soins. Ce rôle essentiel soutient les décisions cliniques basées sur des preuves et nécessite d'excellentes compétences en communication.

Qualifications

• MD ou DO requis, licence médicale non restreinte.
• Certification de conseil médical requise.
• Minimum d'expérience clinique requis.

Responsibilities

• Réaliser des évaluations de nécessité médicale pour les recours et consultations.
• Interpréter et appliquer les politiques de santé et les normes réglementaires.
• Communiquer directement avec les fournisseurs pendant les discussions.

Skills

Clinical experience

Communication skills

Knowledge of managed care processes

Clinical documentation

Education

MD or DO degree from an accredited medical school

Current, unrestricted medical license

Board certification in a medical specialty

Job description

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 – 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.).