HJ STAFFING is seeking two (2) experienced, detail-oriented Physician Advisors – Peer-to-Peer (P2P) Medical Reviewers to conduct clinical discussions with treating providers regarding utilization management determinations.
In this role, you will apply Medicare/CMS requirements, applicable medical necessity criteria, health plan policies, and clinical judgment to determine the appropriate level of care and/or medical necessity of requested services. You will support timely, consistent, evidence-based utilization management while providing treating physicians the opportunity to discuss relevant clinical information before or following an adverse determination, as applicable.
What You Will Do
- Conduct Peer-to-Peer Reviews: Lead scheduled and ad hoc P2P discussions with treating physicians and other qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests.
- Review & Evaluate Cases: Analyze member clinical documentation, utilization management reviews, applicable criteria, and rationale prior to P2P discussions. Evaluate medical necessity and level of care (inpatient vs. observation/outpatient status).
- Apply Regulatory & Clinical Criteria: Utilize CMS Medicare Advantage requirements, the Two-Midnight benchmark, NCDs/LCDs, MCG or other approved clinical criteria, and health plan policies.
- Engage & Collaborate Collegially: Discuss clinical rationales professionally with treating providers. Consider new clinical information during P2P discussions and adjust medical necessity determinations or overturn proposed adverse determinations when supported, within delegated authority.
- Documentation & Compliance: Accurately and contemporaneously document P2P discussions, clinical details, participants, outcomes, and rationale within required regulatory and organizational turnaround times. Maintain strict HIPAA compliance.
- Escalation & Leadership: Escalate complex, high-risk, or unclear cases to Medical Directors or clinical leadership. Lead case review discussions on clinical Joint Operating Committees (JOCs).
- Identify Trends: Spot recurring clinical, documentation, or provider-education opportunities and communicate trends to utilization management leadership.
What You Will Bring
- Degree: MD or DO from an accredited medical school.
- Licensure: Active, current, and unrestricted U.S. medical license.
- Board Certification: Board certification in an appropriate clinical specialty (Internal Medicine, Family Medicine, Emergency Medicine, or another specialty with broad medical experience is preferred).
- Clinical Experience: 5+ years of clinical practice experience is preferred.
- Utilization Management Experience: Prior experience in utilization management, medical necessity review, physician advisory services, payer medical review, or hospital case management is strongly preferred.
- Regulatory & Criteria Knowledge: Strong familiarity with Medicare Advantage, CMS coverage requirements, MCG, InterQual, NCD/LCD criteria, and the Two-Midnight rule.
- Communication & Judgment: Exceptional physician-to-physician communication skills, with the ability to professionally navigate difficult or disputed clinical discussions, make sound medical necessity determinations, and distinguish clinical decisions from administrative/contractual issues.