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Healthfirst Logo Healthfirst · Health and Beauty

Medical Peer Reviewer

United States 122907.00 - 188020.00 USD / Year · Job Posted April 10, 2026
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Job Description

A vital role of the CMO Administration team, the Medical Peer Reviewer plays a critical role in consulting on medical necessity in the context of utilization management and ensuring adherence 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
  • Responsibilities may be adjusted based on changing needs of the organization

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
  • Board Certified in Internal Medicine, Family Practice, OBGYN, Emergency Medicine (Preferred)
  • Previous, relevant experience in utilization management and clinical practice (Preferred)
  • Knowledge of Medicare, Medicaid, and MLTC plans (Preferred)
  • Time management, critical thinking, communication, and problem-solving skills (Preferred)
  • Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies (Preferred)
  • Knowledge of member satisfaction/incident management and regulations (Preferred)
  • Knowledge of quality improvement methodologies (Preferred)
  • Ensures compliance to internal Healthfirst and external regulations
  • Annual Compliance and other training as assigned
  • Annual Inter-Rater Reliability (IRR) Testing
  • Complies with the Healthfirst Conflict of Interest Policy for Professionals

What we offer

  • Medical, dental and vision coverage
  • Incentive and recognition programs
  • Life insurance
  • 401k contributions
  • Paid Time Off (PTO)
  • Holiday pay and straight hours worked for covering one legal holiday/year
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