Job Description

Position Summary The Physician Advisor (1099 Contractor) is a licensed physician responsible for conducting clinical discussions with treating providers regarding utilization management determinations. The physician applies 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. The role supports timely, consistent, evidence-based utilization management while providing treating physicians an opportunity to discuss relevant clinical information before or following an adverse determination, as applicable. Key Responsibilities - 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 the member's clinical documentation, utilization management review, applicable criteria, and rationale for the proposed or issued determination before the P2P discussion. - 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. - Discuss the clinical rationale for determinations clearly, professionally, and collegially with treating providers. - Consider additional clinical information presented during the P2P 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. - Document P2P discussions accurately and contemporaneously, including the clinical information discussed, physician participants, outcome, 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 UM 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 Qualifications - 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 preferred. - Minimum of 5 years of clinical practice experience preferred. - Experience with utilization management, medical necessity review, physician advisory services, payer medical review, or hospital case management strongly preferred. - Experience with Medicare Advantage and CMS medical necessity/coverage requirements preferred. - Familiarity with MCG, InterQual, CMS coverage policies, and the Two-Midnight rule preferred. - Strong physician-to-physician communication skills and the ability to manage difficult or disputed clinical discussions professionally.

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