Physician Advisor – (P2P) Medical Reviewer (1099 Contractor)
Core
Licensed physician conducting peer-to-peer clinical discussions to determine medical necessity and level of care for Medicare Advantage members.
Role type
Physician Advisor (1099 Contractor)
Builds
Utilization management determinations for health plans
Domain
Healthcare / Medicare Advantage / Utilization Management
Deliverable
client delivery
Required skills
Clinical judgment, Medical necessity assessment, Level-of-care determination, CMS/Medicare policy application, Peer-to-peer communication, Clinical documentation, HIPAA compliance, Conflict resolution
Preferred skills
Board certification in Internal Medicine/Family Medicine/Emergency Medicine, 5+ years clinical practice, Utilization management experience, Medicare Advantage experience, Familiarity with MCG/InterQual/Two-Midnight rule
Technologies
MCG, InterQual, CMS guidelines
Responsibilities
Conduct peer-to-peer discussions with treating physicians, Review clinical documentation and utilization management reviews, Evaluate medical necessity and level of care, Apply CMS Medicare Advantage requirements and clinical criteria, Discuss clinical rationale with providers, Approve or overturn adverse determinations, Escalate complex cases, Document P2P discussions, Identify recurring clinical trends
Seniority
Senior, hands-on IC