Physician Reviewer- REMOTE
Posted 2025-08-26
Remote, USA
Part Time
Immediate Start
Job Summary
We are seeking a board-certified physician (MD or DO) with clinical experience and knowledge of managed care processes to conduct peer-to-peer reviews, and review appeals and grievances for medical necessity, appropriateness of care, and compliance with health plan policies. The ideal candidate will ensure clinical decisions support evidence-based care and regulatory guidelines.
Primary Responsibilities
• Conduct medical necessity reviews for appeals, grievances, and peer-to-peer consultations.
• Interpret and apply health plan policies, clinical guidelines, and regulatory requirements.
• Communicate directly with requesting providers during peer-to-peer discussions.
• Document clinical determinations and rationale clearly and concisely.
• Collaborate with internal teams including case managers, utilization review nurses, and compliance staff.
• Participate in committee meetings, audits, and quality improvement initiatives as needed.
Education and Experience
• MD or DO degree from an accredited medical school.
• Current, unrestricted medical license in the United States.
• Board certification in a medical specialty.
• Minimum of 3-5 years of clinical experience, preferably with experience in managed care or utilization management.
• Prior experience with appeals, grievances, or peer review is highly desirable.
• Excellent communication and clinical documentation skills.
• Knowledge of regulatory standards (CMS, NCQA, URAC, etc.).
Apply to This Job
We are seeking a board-certified physician (MD or DO) with clinical experience and knowledge of managed care processes to conduct peer-to-peer reviews, and review appeals and grievances for medical necessity, appropriateness of care, and compliance with health plan policies. The ideal candidate will ensure clinical decisions support evidence-based care and regulatory guidelines.
Primary Responsibilities
• Conduct medical necessity reviews for appeals, grievances, and peer-to-peer consultations.
• Interpret and apply health plan policies, clinical guidelines, and regulatory requirements.
• Communicate directly with requesting providers during peer-to-peer discussions.
• Document clinical determinations and rationale clearly and concisely.
• Collaborate with internal teams including case managers, utilization review nurses, and compliance staff.
• Participate in committee meetings, audits, and quality improvement initiatives as needed.
Education and Experience
• MD or DO degree from an accredited medical school.
• Current, unrestricted medical license in the United States.
• Board certification in a medical specialty.
• Minimum of 3-5 years of clinical experience, preferably with experience in managed care or utilization management.
• Prior experience with appeals, grievances, or peer review is highly desirable.
• Excellent communication and clinical documentation skills.
• Knowledge of regulatory standards (CMS, NCQA, URAC, etc.).
Apply to This Job