Physician Peer Reviewer Jobs

Healthfirst

Location:
United States

Category:
Health and Beauty

Contract Type:
Not provided

Salary:

122907.00 - 188020.00 USD / Year

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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

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
Annual Compliance and other training as assigned, may include but not limited to hardware, software, and system training upgrades
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

Additional Information:

Job Posted:
December 09, 2025

Employment Type:

Parttime

Work Type:

Remote work

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Physician Peer Reviewer