Physician Advisor- Peer-to-Peer Medical Reviewer

HJ Staffing•Eagan, MN

About The Position

HJ STAFFING is seeking two experienced, detail-oriented Physician Advisors to conduct peer-to-peer (P2P) clinical discussions with treating providers regarding utilization management determinations. The role applies 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. It supports timely, consistent, evidence-based utilization management and gives treating physicians an opportunity to discuss relevant clinical information before or following an adverse determination, as applicable.

Requirements

MD or DO degree from an accredited medical school.
Active, current, and unrestricted U.S. medical license.
Strong familiarity with Medicare Advantage, CMS coverage requirements, MCG, InterQual, NCD/LCD criteria, and the Two-Midnight rule.
Exceptional physician-to-physician communication skills and the ability to professionally navigate difficult or disputed clinical discussions.
Ability to make sound medical necessity determinations and distinguish clinical decisions from administrative or contractual issues.
Strict adherence to HIPAA compliance.

Nice To Haves

Board certification in an appropriate clinical specialty; Internal Medicine, Family Medicine, Emergency Medicine, or another specialty with broad medical experience is preferred.
Five or more years of clinical practice experience.
Prior experience in utilization management, medical necessity review, physician advisory services, payer medical review, or hospital case management.

Responsibilities

Lead scheduled and ad hoc peer-to-peer discussions with treating physicians and other qualified providers concerning 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 or 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.
Document peer-to-peer discussions, clinical details, participants, outcomes, and rationale accurately and contemporaneously within required regulatory and organizational turnaround times.
Maintain strict HIPAA compliance.
Escalate complex, high-risk, or unclear cases to Medical Directors or clinical leadership.
Lead case review discussions on clinical Joint Operating Committees (JOCs).
Identify recurring clinical, documentation, or provider-education opportunities and communicate trends to utilization management leadership.