Medical Reviewer

• 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

Physician Advisor – Peer-to-Peer Medical Reviewer

• Conduct thorough reviews of clinical cases
• Evaluate medical records
• Provide clinical summaries
• Engage in peer communications
• Answer specific questions posed by clients

Medical Reviewer jobs in Minnesota

Physician Advisor – Peer-to-Peer Medical Reviewer

Board Certified Physician Reviewer – Medical Oncology