Physician Reviewer- REMOTE

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 tot his job Apply To this Job