Physician Advisor- Peer-to-Peer Medical Reviewer

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.

• 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.

• 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.