Physician Reviewer- REMOTE
Job Summary
We are seeking a board-certified physician (MD or DO) with clinical experience and knowledge of managed care processes to conduct peer-to-peer reviews, and review appeals and grievances for medical necessity, appropriateness of care, and compliance with health plan policies. The ideal candidate will ensure clinical decisions support evidence-based care and regulatory guidelines.
Primary Responsibilities
ā¢ Conduct medical necessity reviews for appeals, grievances, and peer-to-peer consultations.
ā¢ Interpret and apply health plan policies, clinical guidelines, and regulatory requirements.
ā¢ Communicate directly with requesting providers during peer-to-peer discussions.
ā¢ Document clinical determinations and rationale clearly and concisely.
ā¢ Collaborate with internal teams including case managers, utilization review nurses, and compliance staff.
ā¢ Participate in committee meetings, audits, and quality improvement initiatives as needed.
Education and Experience
ā¢ MD or DO degree from an accredited medical school.
ā¢ Current, unrestricted medical license in the United States.
ā¢ Board certification in a medical specialty.
ā¢ Minimum of 3-5 years of clinical experience, preferably with experience in managed care or utilization management.
ā¢ Prior experience with appeals, grievances, or peer review is highly desirable.
ā¢ Excellent communication and clinical documentation skills.
ā¢ Knowledge of regulatory standards (CMS, NCQA, URAC, etc.).
Apply Now
Apply Now
We are seeking a board-certified physician (MD or DO) with clinical experience and knowledge of managed care processes to conduct peer-to-peer reviews, and review appeals and grievances for medical necessity, appropriateness of care, and compliance with health plan policies. The ideal candidate will ensure clinical decisions support evidence-based care and regulatory guidelines.
Primary Responsibilities
ā¢ Conduct medical necessity reviews for appeals, grievances, and peer-to-peer consultations.
ā¢ Interpret and apply health plan policies, clinical guidelines, and regulatory requirements.
ā¢ Communicate directly with requesting providers during peer-to-peer discussions.
ā¢ Document clinical determinations and rationale clearly and concisely.
ā¢ Collaborate with internal teams including case managers, utilization review nurses, and compliance staff.
ā¢ Participate in committee meetings, audits, and quality improvement initiatives as needed.
Education and Experience
ā¢ MD or DO degree from an accredited medical school.
ā¢ Current, unrestricted medical license in the United States.
ā¢ Board certification in a medical specialty.
ā¢ Minimum of 3-5 years of clinical experience, preferably with experience in managed care or utilization management.
ā¢ Prior experience with appeals, grievances, or peer review is highly desirable.
ā¢ Excellent communication and clinical documentation skills.
ā¢ Knowledge of regulatory standards (CMS, NCQA, URAC, etc.).
Apply Now
Apply Now