Physician Advisor- Peer-to-Peer Medical Reviewer

Accountabilities:: Conduct scheduled and ad hoc peer-to-peer discussions with treating physicians and qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests. Review member clinical documentation, utilization management assessments, applicable criteria, and case rationale before peer-to-peer discussions. Evaluate medical necessity and determine the appropriate level of care, including inpatient versus observation or outpatient status. Apply Medicare Advantage and CMS requirements, the Two-Midnight benchmark, NCDs, LCDs, MCG or other approved clinical criteria, and applicable health plan policies. Engage professionally with treating providers, consider new clinical information presented during discussions, and adjust or overturn proposed adverse determinations when supported and within delegated authority. Accurately document peer-to-peer discussions, clinical information, participants, outcomes, and rationale within required regulatory and organizational turnaround times. Maintain strict compliance with HIPAA and applicable clinical and regulatory requirements. Escalate complex, high-risk, or unclear cases to Medical Directors or appropriate clinical leadership. Lead case review discussions during clinical Joint Operating Committees (JOCs) as needed. Identify recurring clinical, documentation, or provider-education trends and communicate relevant opportunities to utilization management leadership. Requirements: MD or DO degree from an accredited medical school. Active, current, and unrestricted U.S. medical license. Board certification in an appropriate clinical specialty; Internal Medicine, Family Medicine, Emergency Medicine, or another specialty with broad medical experience is preferred. 5+ years of clinical practice experience preferred. Prior experience in utilization management, medical necessity review, physician advisory services, payer medical review, or hospital case management is strongly preferred. Strong knowledge of Medicare Advantage and CMS coverage requirements. Familiarity with MCG, InterQual, NCD/LCD criteria, and the Two-Midnight rule. Exceptional physician-to-physician communication skills and the ability to navigate difficult or disputed clinical discussions professionally. Strong clinical judgment and the ability to make sound medical necessity determinations. Ability to distinguish clinical decisions from administrative or contractual considerations. Strong attention to detail, documentation, compliance, and timely case management. Ability to collaborate effectively with clinical leadership, treating providers, and utilization management teams. Benefits: Full-time position. Remote work arrangement. Opportunity to perform meaningful physician-to-physician clinical review and utilization management work. Direct involvement in medical necessity and level-of-care determinations. Exposure to Medicare Advantage, CMS requirements, clinical criteria, and health plan utilization management processes. Opportunity to collaborate with treating providers, Medical Directors, clinical leadership, and utilization management teams. Opportunities to contribute to clinical Joint Operating Committees and provider-education initiatives. Specific salary, healthcare, retirement, paid time off, and additional benefits were not specified in the source job description.