Physician 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

Utilization Management Physician Reviewer

Full-time role responsible for provisioning accurate and timely coverage determi...

Location

United States , Remote

Salary:

174070.00 - 374920.00 USD / Year

CVS Health

Expiration Date

August 21, 2026

Requirements

At least one year experience providing Utilization Management services to a Medicare and/or Medicaid line of business
Excellent verbal and written communication skills
A current, clinical, unrestricted license to practice medicine in the United States
Graduate of an accredited medical school with M.D. or D.O. Degree
3-5 years of clinical practice in a primary care setting
Deep understanding of managed care, risk arrangements, capitation, peer review, performance profiling, outcome management, care coordination, and pharmacy management
Strong record of continuing education activities
Demonstrated understanding of culturally responsive care
Proven organizational and detail-orientation skills
US work authorization

Job Responsibility

Review service requests and document the rationale for the decision
Use evidence-based criteria and clinical reasoning to make UM determinations
Work collaboratively with the Oak Street Health Transitional Care and PCP care teams
Maintain knowledge of current CMS and MCG evidence-based guidelines
Maintain compliance with legal, regulatory and accreditation requirements
Participate in initiatives to achieve and improve UM imperatives
Assist in formal responses to health plan regarding UM process
Adhere to regulatory and accreditation requirements of payor partners
Participate in rounding and patient panel management discussions
Fulfill on-call requirement

What we offer

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
Wellness screenings
Tobacco cessation and weight management programs
Confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources

Fulltime

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

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

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

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

Vice President, Nursing Quality and Safety

The Vice President, Nursing Quality and Safety (VP) provides strategic leadershi...

Location

United States , Wilmington

Salary:

Not provided

Kirby Bates Associates

Expiration Date

Until further notice

Requirements

Bachelor’s and Master’s degree required, one of which must be in nursing
Current or eligible for Registered Nurse licensure in the State of Delaware
Nurse Leader certification required
Minimum of five years of progressive system leadership experience with demonstrated success working across interprofessional teams to design, implement, and sustain evidence‑based quality and safety programs and improve outcomes
Formal Lean Six Sigma training required (or willingness to obtain within two years)
Knowledge of current nursing practice standards, The Joint Commission, CMS, Magnet, State, and other regulatory requirements

Job Responsibility

Provides strategic leadership and enterprise oversight for nursing quality, patient safety, and performance improvement
Advances a culture of safety, implementing evidence‑based practice, and continuous improvement of outcomes
Oversees key nursing functions, including Nursing Quality & Safety, Wound Ostomy Continence Nursing, and the WISH Program
Serves as a trusted advisor and mentor to nurse leaders, frontline teams, and members of the systemwide Nursing Quality and Safety Council as well as Event Based Nursing Peer Review
Partners closely with nursing leaders, physicians, clinical teams, and enterprise leaders across Quality, Patient Safety, Risk Management, Accreditation, and Information Technology
Shape and advance systemwide nursing quality, patient safety, and performance improvement strategies with direct influence on outcomes
Lead and develop high‑impact programs focused on evidence‑based practice, event review, peer review, and human factors
Partner with executive, clinical, and operational leaders to design and sustain data‑driven, outcome focused quality initiatives
Oversee nursing quality analytics and external reporting, including NDNQI, Magnet, and Leapfrog

New

Rn Quality Pediatric Cardiac Icu/transplant Specialist

The Data Quality Specialist is responsible for abstracting, analyzing and submit...

Location

United States , Hollywood

Salary:

Not provided

Memorial Healthcare System

Expiration Date

Until further notice

Requirements

Accredited Program: Nursing
Registered Nurse License (RN LICENSE) - State of Florida (FL)
Three (3) years of experience in areas of clinical focus
Florida licensure as a Registered Nurse or trained medical Physician

Job Responsibility

Serves as a resource person to the Medical Staff, Nursing and Ancillary Departments and performs validation audits/rounds and education as needed to assess regulatory/standard compliance as assigned
Effectively hosts and or participates in live or virtual meetings utilizing virtual meeting platforms on-site or from a remote location as needed and as assigned
Investigates incident reports, patient complaints, patient care issues
acts as a resource on quality issues and contributes to problem solving of identified quality/risk issues as assigned
Assists in the collection, coordination, formation, implementation, benchmarking and reporting of key performance indicators
Performs comprehensive, concurrent, and retrospective clinical reviews and abstractions as assigned
Works with the Chief Medical Officer and Medical Staff Department Chairpersons on Peer Review activities and prepares QI reports for Medical Department Meetings
Facilitates Medical Staff Peer Review and all activities related to Departmental and Multidisciplinary Peer Review as assigned
Utilizes and interprets information obtained from MHS Quality Improvement Technology Platforms as well as external quality data platforms to obtain quality data for benchmarking as assigned

Fulltime

Physician Peer Reviewer

Healthfirst

Location:
United States

Category:
Health and Beauty

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
January 03, 2026

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