Physician Advisor – Peer-to-Peer Medical Reviewer

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🔥 1 minute ago

❄️ Minnesota – Remote

❄️ Minnesota – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

👻 Ghost score 12%

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HJ Staffing

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HJ Staffing is a premier staffing agency dedicated to providing tailored workforce solutions for businesses across various industries. With a focus on delivering exceptional human resources support, HJ Staffing connects leading companies with outstanding talent through temporary staffing, direct placement, and human resource consulting. The company serves clients in multiple states including Texas, Louisiana, Delaware, and California, asserting its commitment to a personalized approach and superior customer service in every client relationship.

📋 Description

• Lead scheduled and ad hoc peer-to-peer discussions with treating physicians and other qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests • Analyze member clinical documentation, utilization management reviews, applicable criteria, and rationale before peer-to-peer discussions • Evaluate medical necessity and level of care, including inpatient versus observation/outpatient status • Apply CMS Medicare Advantage requirements, the Two-Midnight benchmark, NCDs/LCDs, MCG or other approved clinical criteria, and health plan policies • Discuss clinical rationales professionally with treating providers • Consider new clinical information and adjust medical necessity determinations or overturn proposed adverse determinations when supported and within delegated authority • Accurately and contemporaneously document peer-to-peer discussions, clinical details, participants, outcomes, and rationale within required regulatory and organizational turnaround times • Escalate complex, high-risk, or unclear cases to Medical Directors or clinical leadership • Lead case review discussions on clinical Joint Operating Committees • Identify recurring clinical, documentation, or provider-education opportunities and communicate trends to utilization management leadership

🎯 Requirements

• MD or DO from an accredited medical school • Active, current, and unrestricted U.S. medical license • Board certification in an appropriate clinical specialty is preferred, including Internal Medicine, Family Medicine, Emergency Medicine, or another specialty with broad medical experience • 5+ years of clinical practice experience is preferred • Prior experience in utilization management, medical necessity review, physician advisory services, payer medical review, or hospital case management is strongly preferred • Strong familiarity with Medicare Advantage, CMS coverage requirements, MCG, InterQual, NCD/LCD criteria, and the Two-Midnight rule • Exceptional physician-to-physician communication skills • Ability to professionally navigate difficult or disputed clinical discussions • Ability to make sound medical necessity determinations • Ability to distinguish clinical decisions from administrative/contractual issues • Strict HIPAA compliance

🏖️ Benefits

• Remote work arrangement

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