Job Description
Job Summary 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 that determinations are made in accordance with established clinical guidelines, regulatory requirements, and health plan policies, while maintaining 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.
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