Medical Peer Reviewer Job at Healthfirst

Physician Peer Reviewer

A vital role of the CMO Administration team, the Medical Peer Reviewer plays a c...

Location

United States

Salary:

122907.00 - 188020.00 USD / Year

Healthfirst

Expiration Date

Until further notice

Requirements

Licensed M.D. or D.O. or D.M.D. or D.D.S.
Board Certified in a specialty recognized by the American Board of Medical Specialties
New York State Board Certified in Internal Medicine or Family Practice
Previous, relevant experience in utilization management and clinical practice
Knowledge of Medicare, Medicaid, and MLTC plans
Time management, critical thinking, communication, and problem-solving skills
Knowledge of UM//QM case philosophies and reporting requirements to state and federal agencies
Knowledge of member satisfaction//incident management and regulations
Knowledge of quality improvement methodologies
Ensures compliance to internal Healthfirst and external regulations

Job Responsibility

Assess//review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations
Render determinations in the format and within timeframes to follow Regulatory and Operational policies
Maintain productivity standards
Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases//caseload from multiple lines of businesses
Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members//internal medical departments as needed
Complete mandatory Company compliance training and training in new systems and software
Enter each day’s hours worked in Workday, on the same day
Perform other duties as assigned

What we offer

medical, dental and vision coverage
incentive and recognition programs
life insurance
401k contributions
Paid Time Off (PTO)
Holiday pay

Parttime

Regulatory Data Analyst

The Regulatory Data Analyst plays a crucial role in delivering high-quality heal...

Location

United States , Charleston

Salary:

Not provided

MUSC Health

Expiration Date

Until further notice

Requirements

Required bachelor’s degree in healthcare administration, nursing, data analytics, public health, or related field
3 years of experience in healthcare quality improvement, regulatory compliance, medical staff services, or healthcare data analytics

Job Responsibility

Facilitation of Peer Review Processes
Coordinates Physician Peer Review and Professionalism process across clinical departments
Oversees cases submitted for peer review and assigns them to the appropriate specialty reviewers
Supports Professionalism and Peer Review Committees/sub-committees by preparing agendas, collecting data, documenting minutes, and following up on action items
Monitor completion of peer review cases and escalate delays
Analyze clinical performance data and compile practitioner performance profiles for department chairs and credentialing committees
Identify trends in professionalism and peer review outcomes that indicate practitioner performance issues, and system or process failures
Regulatory Compliance and Accreditation
Remain current with regulatory requirements and accreditation standards, i.e., CMS, DPH, and Joint Commission
Assist in preparing for regulatory inspections and accreditation surveys

Fulltime

Behavioral Health Medical Director

The Behavioral Health Medical Administrator (Medical Director) directs, leads, a...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

3 years of experience in a clinical setting
1 year of experience in physician leadership role, including quality review, utilization review, population health and other managed care functions
Medical Degree
Active, current, and unrestricted license to practice medicine in the State of Arizona (a state in the United States)
Board Certification in general psychiatry, or adult and child/adolescent psychiatry, through the American Board of Psychiatry and Neurology
Requires knowledge and skills in state (Arizona) and federal behavioral health regulations, requirements for publicly funded services, delivery, operations, and licensure.
Knowledge of managed care concepts and practices
and emerging and best practices for adult & children’s integrated care programs.
Ability to use electronic word processing, email, and electronic database resources.
Excellent customer service and oral/written communication skills

Job Responsibility

Directs, leads, and provides professional oversight for medical management and population health activities related to behavioral health utilization management, case and care management, disease management, performance improvement, and quality management activities.
Supports collaborative relationships with physicians and hospitals to achieve mutually acceptable business goals in compliance with AHCCCS and CMS regulations.
Provides physician leadership and medical oversight in the design, implementation and review of clinical services, best practices, care management, medical management and quality management.
Serves as liaison between the Medicaid Business Segment and medical and behavioral health practitioners at stakeholder and provider agencies.
Participates in aggregate and member-level clinical analyses for quality management, quality of care concerns, peer review, medical management, and utilization review processes.
Reviews and authorizes requests by providers and treatment coordinators for services or programs requiring prior authorization.
Participates in the design and implementation of best practices, clinical standards, protocols, and treatment guidelines.
Participates in credentialing, re-credentialing and competency processes for providers.
Assists care managers with care management of high risk/high-cost members.
Participates as a member or chair of internal and external committees.

Parttime

Ambulatory Clinical Pharmacist - Neurology

The Ambulatory Clinical Pharmacist provides comprehensive pharmaceutical care fo...

Location

United States , Kansas City

Salary:

Not provided

The University of Kansas Health System

Expiration Date

Until further notice

Requirements

Bachelors Degree in Pharmacy from an accredited college or university
Licensed Pharmacist - State Board of Pharmacy in state of primary practice site
Advanced Cardiac Life Support (ACLS) - American Heart Association (AHA) certification as necessary
Pediatric Advanced Life Support (PALS) and/or Neonatal Resuscitation Program (NRP) certification as necessary
Basic Cardiac Life Support (BLS or BCLS) - American Heart Association (AHA)

Job Responsibility

Actively participates in organizational and departmental performance improvement efforts to strengthen existing systems, processes, policies and procedures by introducing new ideas that lead to improved pharmaceutical care in clinical areas and in the pharmacy department as a whole
Actively participates on the multidisciplinary team by consistently attending patient care rounds and providing patient – focused pharmaceutical care by assessing and monitoring drug therapy to ensure safe and cost – conscious treatment regimens
Actively supports department staffing needs by flexing to other areas or alternative scheduling in order to assist in coverage of supplemental shifts when primary team is in need
Assures timely medication order processing by participating in order entry, order verification and reviewing medication orders for timely resolution of problem orders
Completes patient-specific medication profile reviews resulting in execution of protocol based drug therapy including, but not limited to pharmacokinetic dosing and IV to PO conversions with appropriate documentation. Adjusts doses as appropriate for patient specific parameters such as renal or hepatic dysfunction
Continually reports medication incidents and adverse drug reactions in Patient Safety Net (PSN) and participates in medication incident review, peer review, or other activities to establish safe medication systems
Participates in medication reconciliation at the time of admission, transfer, and/or discharge and provides patient education when appropriate
Shares pharmaceutical expertise by coordinating and providing educational presentations or in-services for pharmacy and non-pharmacy staff
Supports pharmacy residency programs, clerkship students and interns by precepting organized rotations, providing timely and constructive feedback, participating in training and orientation, providing mentorship, and collaborating on presentations and projects
Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department

Medical Director of Revenue Integrity

The Physician Advisor is a key member of the healthcare organization’s leadershi...

Location

United States , Cheyenne

Salary:

Not provided

Cheyenne Regional Medical Center

Expiration Date

Until further notice

Requirements

Hold and maintain or able to obtain an unrestricted medical license in the state of Wyoming
Possess or acquires a solid foundation, knowledge, and/or experience in the areas of utilization management, quality improvement, and patient safety
Familiarity with InterQual and MCG is preferred
Strong understanding of Medicare Two Midnight Rules
Member of the American College of Physician Advisors (ACPA)
Board Certification by the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) or ACPA is required within 6 months of hire
Ability to build rapport with medical staff and hospital leadership to obtain the buy-in and collaboration necessary to achieve desired outcomes
Prefer Internal Medicine specialist with a background in Hospital Medicine
Maintain active medical practice in their specialty (Can accommodate clinical time up to 0.15 FTE in the specialty (depending on availability))
Demonstrates behavior that supports the organization’s mission

Job Responsibility

Provide functional leadership for the revenue integrity team Including CDI, Coding and Utilization Review
Responsible for oversight revenue integrity optimization
Lead value-based care initiatives for the organization
Chairs the Utilization Management Team
Review medical records of patients identified by case managers or as requested by the healthcare team including physicians to perform quality and utilization oversight
Perform medical necessity reviews including initial level of care, secondary reviews, and continued stay reviews
Conduct Peer to Peer discussion with Payor Medical Directors when requested
Provide regular feedback to physicians and all other stake holders regarding level of care, length of stay, and potential quality issues
Provide necessary clinical education to UR Case Managers regarding clinical criteria and appropriate use of screening tools
Educates individual hospital staff physicians about ICD-10 and DRG coding guidelines (e.g., co-morbid conditions, outpatient vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records

What we offer

403(b) with 4% employer match
ANCC Magnet Hospital
$10,000 relocation bonus
$3,500 in CMEs
216 hours of PTO
Robust Benefits Package

Clinical Pharmacist Supervisor - Ambulatory Clinical Services

The Clinical Pharmacist Supervisor for Ambulatory Clinical Services will report ...

Location

United States , Lenexa

Salary:

Not provided

The University of Kansas Health System

Expiration Date

Until further notice

Requirements

Bachelors Degree or Doctorate in Pharmacy
Completion of an ASHP accredited PGY-1 and PGY-2 Pharmacy Residency Program OR Completion of an ASHP accredited PGY-1 and PGY-2 Pharmacy Administration Residency Program OR Completion of an ASHP accredited PGY-1 Pharmacy Residency Program plus years of practice experience in area of focus
4 or more years of practice experience in area of focus in lieu of residency
Licensed Pharmacist - State Board of Pharmacy by the applicable State Board of Pharmacy prior to employment
Basic Cardiac Life Support (BLS or BCLS) - American Heart Association (AHA)
Candidates should have 3-5+ years of clinical experience and be interested in leadership

Job Responsibility

Leading bi-weekly check-ins with pharmacists
Overseeing Workday check-ins
Approving timecards and creating a plan for pharmacist coverage
Identifying and escalating workflow issues or opportunities to the clinical manager
Assisting with optimizing the pharmacist and PPA working relationship and associated operations
Being involved in PPA operations and oversight
Maintaining a staffing component in a clinic setting
Demonstrates competence in the area of critical thinking, interpersonal relationships and technical skills
Demonstrates ability to provide care/service safely and efficiently for the care of each patient
Continually reports medication incidents and adverse drug reactions and participates in medication incident review, peer review, or other activities to establish safe medication systems

Fulltime

Clinical Risk Manager

The Clinical Risk Management Department supports and furthers the organization's...

Location

United States , Olathe

Salary:

Not provided

The University of Kansas Health System

Expiration Date

Until further notice

Requirements

Bachelors Degree in Nursing from an accredited college or university
5 or more years of experience as a nurse in a healthcare setting
2 or more years of management experience or leadership role in a healthcare setting
2 or more years of experience in one or more of the following areas: risk management, quality improvement, health information management, healthcare administration, business administration, legal support, or insurance claims investigation, and settlement
Licensed Registered Nurse (LRN) - Single State - State Board of Nursing

Job Responsibility

Participate in day-to-day risk management operations, including risk mitigation, investigations, and responding to safety events
Develops, coordinates, and administers facility-wide systems for risk identification, investigation, and risk reduction
Reviews collected data to identify trends regarding accidents or occurrences, and recommends corrective action to management
Informs leaders of events/incidents, issues, findings, and risk management recommendations
Proactive analysis of patient safety and medical errors processes
Prepares reports for leaders regarding trends/patterns and findings
Exercise professional judgment and critical thinking to facilitate focused investigation and root cause analysis and the development of appropriate corrective action plans
Leads investigations for adverse events and sentinel events
Prepares risk management and patient safety reports to be submitted to the senior leadership, board, and other appropriate committees
Active participation in patient safety activities by providing data to support priorities, clinical risk management expertise, and participating in patient safety projects

Fulltime

Nurse Anesthetist

Location

United States

Salary:

97.75 - 156.40 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Active RN license in state(s) of practice
Active APRN/APRN-FPA/APNP or other APRN license(s) in state(s) of practice
Active national board certification as CRNA by NBCRNA
Active DEA registration prior to hire
Active ACLS, PALS, NRP as required by clinical site/practice and/or role prior to or within 6 months of hire
Master’s Degree in Nursing
Demonstrated high level of clinical proficiency and excellent decision-making skills
Demonstrated ability to work independently and as an effective member of a health care team
Demonstrated ability to adapt to evolving technology and proficiency with the electronic medical record
Excellent communication skills

Job Responsibility

Provides all elements of pre-anesthesia, anesthesia and post-anesthesia services including general, regional, and monitored anesthesia care
Manages conditions based on clinical indication, evidence-based care, cost effectiveness, and assessment of risks/benefits and alternatives
Participates in preoperative evaluation including assessment, exam, obtaining informed consent, ordering/administering pre‐medications, requesting and/or review of preoperative studies
Ensures readiness and availability of equipment, supplies and medications to perform the planned anesthetic
Delivers anesthesia care including induction, maintenance, support of life functions, and emergence from anesthesia
Selects, obtains, and administers the necessary anesthetics, adjuvant drugs, fluids, and temperature regulating devices
Performs post-anesthesia duties including remaining with the patient and facilitating safe transfer of care
Manage emergency situations by assessing, stabilizing, and determining disposition of patients
Maintains accurate, complete, concise, and timely documentation in the electronic medical record
Participates in quality, safety and peer review initiatives/performance activities, organizational and/or departmental meetings and committees, peer review, and workgroups

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance

Fulltime

Medical Peer Reviewer

Healthfirst

Location:
United States

Category:
Health and Beauty

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Additional Information:

Job Posted:
April 10, 2026

Looking for more opportunities? Search for other job offers that match your skills and interests.

Similar Jobs for Medical Peer Reviewer

Physician Peer Reviewer

Regulatory Data Analyst

Behavioral Health Medical Director

Ambulatory Clinical Pharmacist - Neurology

Medical Director of Revenue Integrity

Clinical Pharmacist Supervisor - Ambulatory Clinical Services

Clinical Risk Manager

Nurse Anesthetist

Medical Peer Reviewer

Healthfirst

Location:United States

Category:Health and Beauty

Contract Type:Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Additional Information:

Job Posted:April 10, 2026

Looking for more opportunities? Search for other job offers that match your skills and interests.

Similar Jobs for Medical Peer Reviewer

Physician Peer Reviewer

Regulatory Data Analyst

Behavioral Health Medical Director

Ambulatory Clinical Pharmacist - Neurology

Medical Director of Revenue Integrity

Clinical Pharmacist Supervisor - Ambulatory Clinical Services

Clinical Risk Manager

Nurse Anesthetist

Location:
United States

Category:
Health and Beauty

Contract Type:
Not provided

Job Posted:
April 10, 2026