Job Description

Overview The Physician Reviewer is responsible for conducting clinical peer-to-peer reviews and medical necessity determinations on complex medical claims, appeals, and utilization review cases for a third-party administrator (TPA) or health plan. This position ensures determinations are made in accordance with established clinical guidelines, regulatory requirements, and health plan policies, with a strong focus on evidence-based medicine and fair, timely adjudication. Primary Responsibilities Clinical Review: Conduct medical necessity, appropriateness, and level-of-care reviews for inpatient, outpatient, and specialty claims, including complex and high-cost cases. Peer-to-Peer Consultations: Perform peer-to-peer discussions with treating physicians and other providers to review cases, clarify medical necessity, and ensure alignment with clinical guidelines and plan criteria. Documentation: Prepare clear, detailed, and well-supported determinations based on medical records, evidence-based guidelines (e.g., MCG, InterQual), and payer policies. Appeals and Grievances: Participate in first- and second-level appeals processes; review member and provider appeals and render independent medical judgments. Compliance: Ensure all reviews and communications comply with applicable federal and state regulations, including HIPAA, ERISA, NCQA, and URAC standards. Collaboration: Work closely with medical management staff, nurse reviewers, case managers, and claims examiners to ensure consistency, quality, and timeliness of decisions. Quality and Education: Participate in quality improvement initiatives and provide feedback or education to internal staff regarding medical policy interpretations and emerging clinical trends. Education and Experience MD or DO degree from an accredited medical school. Licensure: Active, unrestricted medical license in at least one U.S. state (multi-state licensure preferred). Minimum of 5 years of clinical experience post-residency. Prior experience in utilization management, peer review, or medical claims review for a payer, TPA, or managed care organization strongly preferred. Familiarity with evidence-based guidelines (e.g., MCG, InterQual) and health plan medical policy criteria. Specialties Preferred: Internal Medicine, Family Medicine, Emergency Medicine, or relevant subspecialty (depending on case mix) Strong analytical and clinical reasoning skills. Excellent written and verbal communication skills, especially in peer-to-peer discussions. Proficiency in electronic medical review systems and case management software. Ability to manage workload efficiently and meet turnaround time requirements in a remote setting. High professional integrity and commitment to objective, evidence-based decision-making. Seniority level Mid-Senior level Employment type Contract Job function Health Care Provider Industries Hospitals and Health Care #J-18808-Ljbffr Sierra Solutions

Job Tags

Similar Jobs