[Remote] Physician Peer Reviewer NY Licensed Internal or Family Medicine Board Certified

Note: The job is a remote job and is open to candidates in USA. Healthfirst is seeking a Medical Peer Reviewer to play a vital role in the CMO Administration team. This role involves consulting on medical necessity within utilization management and ensuring compliance with regulations while reviewing authorization requests and claims payments. Responsibilities • The Medical Peer Reviewer will assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations • The Medical Peer Reviewer will render determinations in the format and within timeframes to follow Regulatory and Operational policies • The Medical Peer Reviewer will: • Maintain productivity standards • Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases//caseload from multiple lines of businesses • Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as needed • Complete mandatory Company compliance training and training in new systems and software • Enter each day’s hours worked in Workday, on the same day • Perform other duties as assigned • Responsibilities may be adjusted based on changing needs of the organization • Each Medical Reviewer will cover one legal holiday /year and will be compensated Holiday pay and straight hours worked • The Medical Reviewer is eligible for Paid Time Off (PTO) and is required to plan and schedule time off with their direct supervisor following the Company policy • Each Medical Reviewer is required to be primary coverage one weekend a month • Each Medical Reviewer is required to be available as back up, if needed, one weekend a month Skills • Licensed M.D. or D.O. or D.M.D. or D.D.S • Board Certified in a specialty recognized by the American Board of Medical Specialties • New York State Board Certified in Internal Medicine or Family Practice • Previous, relevant experience in utilization management and clinical practice • Knowledge of Medicare, Medicaid, and MLTC plans • Time management, critical thinking, communication, and problem-solving skills • Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies • Knowledge of member satisfaction/incident management and regulations • Knowledge of quality improvement methodologies Benefits • Medical, dental and vision coverage • Incentive and recognition programs • Life insurance • 401k contributions Company Overview • Healthfirst is a health insurer providing medical, business, and health insurance services. It was founded in 1993, and is headquartered in New York, New York, USA, with a workforce of 1001-5000 employees. Its website is Company H1B Sponsorship • Healthfirst has a track record of offering H1B sponsorships, with 35 in 2025, 26 in 2024, 19 in 2023, 31 in 2022, 3 in 2021, 11 in 2020. Please note that this does not guarantee sponsorship for this specific role. Apply tot his job