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 9/28/2026full-timeRemote • Minnesota • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical necessity determination, utilization management, and peer-to-peer clinical discussions, with a strong understanding of CMS Medicare Advantage requirements and clinical criteria. Possesses exceptional communication skills for effective interactions with treating physicians and clinical leadership.

Highest-signal resume keywords

MD Or DO DegreeActive U.S. Medical LicenseBoard Certification In Clinical SpecialtyUtilization Management ExperienceMedicare Advantage Familiarity

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity ReviewClinical Documentation AnalysisUtilization Management ReviewPeer-To-Peer DiscussionsClinical Rationale EvaluationTwo-Midnight Rule ApplicationNCD/LCD Criteria KnowledgeMCG Guidelines FamiliarityInterQual Criteria KnowledgeCase Management Experience

Soft Skills

Exceptional Communication SkillsProfessional Dispute NavigationSound Decision-Making

Certifications & Qualifications

Board Certification In Appropriate Clinical Specialty

Industry Keywords

CMS Coverage RequirementsHIPAA ComplianceClinical Joint Operating CommitteesProvider Education OpportunitiesHigh-Risk Case Escalation

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
Document peer-to-peer discussions, clinical details, participants, outcomes, and rationale within required regulatory and organizational turnaround times
Maintain strict HIPAA compliance
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 navigate difficult or disputed clinical discussions professionally
Ability to make sound medical necessity determinations
Ability to distinguish clinical decisions from administrative/contractual issues