Physician Advisor- Peer-to-Peer Medical Reviewer
Core
Conduct clinical discussions with treating providers regarding utilization management determinations and requested services, reviewing documentation to assess medical necessity and determine appropriate levels of care.
Role type
Senior IC physician advisor (utilization management)
Builds
Timely, consistent, and compliant case decisions for health plan members
Domain
Healthcare / Utilization Management
Required skills
Clinical judgment, Evidence-based criteria application, CMS/Medicare Advantage regulatory knowledge, Physician-to-physician communication, Complex case evaluation, Process improvement
Preferred skills
Provider education, Collaborative environment navigation
Technologies
CMS guidelines, Health plan policies
Responsibilities
Conduct clinical discussions with treating providers, Review clinical documentation, Assess medical necessity, Determine appropriate levels of care, Apply Medicare Advantage and CMS requirements, Identify opportunities for provider education and process improvement
Seniority
Experienced, hands-on IC