Physician Advisor – Peer-to-Peer Medical Reviewer

HJ Staffing

. Lead scheduled and ad hoc peer-to-peer discussions with treating physicians and other qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests .

Posted 11/5/2026full-timeRemote • Minnesota • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in medical necessity evaluations, utilization management, and peer-to-peer discussions with treating physicians. Proficient in applying CMS Medicare Advantage requirements and maintaining strict HIPAA compliance.

Highest-signal resume keywords

MD Or DO From An Accredited Medical SchoolActive U.S. Medical LicenseBoard Certification In Clinical Specialty5+ Years Of Clinical Practice ExperienceUtilization Management Experience

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Medical Necessity DeterminationClinical Documentation AnalysisUtilization Management ReviewPayer Medical ReviewHospital Case ManagementCMS Coverage RequirementsMCG CriteriaInterQual CriteriaNCD/LCD CriteriaTwo-Midnight Rule

Soft Skills

Exceptional Physician-To-Physician CommunicationProfessional Navigation Of Difficult Discussions

Certifications & Qualifications

Board Certification In Appropriate Clinical Specialty

Industry Keywords

Inpatient CareOutpatient CarePost-Acute CarePeer-To-Peer DiscussionsClinical Joint Operating CommitteesHIPAA Compliance

About the role

Key responsibilities & impact

Lead scheduled and ad hoc peer-to-peer discussions with treating physicians and other qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests
Analyze member clinical documentation, utilization management reviews, applicable criteria, and rationale before peer-to-peer discussions
Evaluate medical necessity and level of care, including inpatient versus observation/outpatient status
Apply CMS Medicare Advantage requirements, the Two-Midnight benchmark, NCDs/LCDs, MCG or other approved clinical criteria, and health plan policies
Discuss clinical rationales professionally with treating providers
Consider new clinical information and adjust medical necessity determinations or overturn proposed adverse determinations when supported and within delegated authority
Accurately and contemporaneously document peer-to-peer discussions, clinical details, participants, outcomes, and rationale within required regulatory and organizational turnaround times
Escalate complex, high-risk, or unclear cases to Medical Directors or clinical leadership
Lead case review discussions on clinical Joint Operating Committees
Identify recurring clinical, documentation, or provider-education opportunities and communicate trends to utilization management leadership

Requirements

What you’ll need

MD or DO from an accredited medical school
Active, current, and unrestricted U.S. medical license
Board certification in an appropriate clinical specialty is preferred, including Internal Medicine, Family Medicine, Emergency Medicine, or another specialty with broad medical experience
5+ years of clinical practice experience is preferred
Prior experience in utilization management, medical necessity review, physician advisory services, payer medical review, or hospital case management is strongly preferred
Strong familiarity with Medicare Advantage, CMS coverage requirements, MCG, InterQual, NCD/LCD criteria, and the Two-Midnight rule
Exceptional physician-to-physician communication skills
Ability to professionally navigate difficult or disputed clinical discussions
Ability to make sound medical necessity determinations
Ability to distinguish clinical decisions from administrative/contractual issues
Strict HIPAA compliance

Benefits

Comp & perks

Remote work arrangement