Location: Fully Remote | Candidates must be available to work Eastern Time (EST) business hours.
Description
Impresiv Health is seeking a Physician Advisor – Peer-to-Peer (P2P) Medical Reviewer 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 scheduled and ad hoc peer-to-peer discussions with treating physicians and other qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests.
- Review member clinical documentation, utilization management reviews, applicable criteria, and the rationale for proposed or issued determinations prior to P2P discussions.
- Evaluate medical necessity and the appropriate level of care, including inpatient versus observation/outpatient status when applicable.
- Apply CMS Medicare Advantage requirements, the Two-Midnight benchmark, applicable NCDs/LCDs, MCG or other approved clinical criteria, and health plan policies as appropriate.
- Clearly, professionally, and collegially discuss the clinical rationale for determinations with treating providers.
- Consider additional clinical information presented during P2P discussions and determine whether it changes the medical necessity determination.
- Approve or overturn a proposed adverse determination when newly presented information supports coverage, within delegated authority and organizational policy.
- Escalate complex, high-risk, or unclear cases to the appropriate Medical Director or clinical leadership.
- Accurately and contemporaneously document P2P discussions, including clinical information discussed, physician participants, outcomes, and rationale.
- Complete P2P requests within established regulatory and organizational turnaround times.
- Identify recurring clinical, documentation, criteria, or provider-education opportunities and communicate trends to utilization management leadership.
- Collaborate with nurses, medical directors, appeals and grievances, provider engagement, and other operational teams as needed.
- Maintain confidentiality and comply with HIPAA, CMS, accreditation, and organizational requirements.
- Lead case review discussions on clinical JOCs.
You Will Be Successful If:
- You consistently apply sound clinical judgment when evaluating medical necessity and level of care.
- You complete P2P reviews within required regulatory and organizational turnaround times.
- You produce accurate, complete, and timely clinical documentation.
- You make medical necessity determinations accurately and consistently.
- You communicate clearly and professionally during physician-to-physician discussions, including difficult or disputed clinical cases.
- You consistently apply applicable clinical criteria, CMS requirements, and organizational policies.
- You effectively distinguish clinical medical-necessity decisions from contractual or administrative issues.
- You collaborate effectively with clinical and operational teams while maintaining responsiveness and professionalism.
- You support strong provider experiences while adhering to CMS and organizational requirements.
What You Will Bring:
- MD or DO from an accredited medical school.
- Current, unrestricted U.S. medical license.
- Board certification in an appropriate clinical specialty. Internal Medicine, Family Medicine, Emergency Medicine, or another specialty with broad medical experience is preferred.
- A minimum of 5 years of clinical practice experience is preferred.
- Experience with utilization management, medical necessity review, physician advisory services, payer medical review, or hospital case management is strongly preferred.
- Experience with Medicare Advantage and CMS medical necessity and coverage requirements is preferred.
- Familiarity with MCG, InterQual, CMS coverage policies, and the Two-Midnight rule is preferred.
- Strong physician-to-physician communication skills and the ability to professionally manage difficult or disputed clinical discussions.
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That’s Impresiv!
