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

New

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

Appeals Medical Director – Medicare

The Appeals Medical Director is responsible for the appeal reviews for physical ...

Location

United States of America , HANOVER; MIAMI; TAMPA; ATLANTA; CHICAGO; NEW YORK; MASON; RICHMOND

Salary:

250236.00 - 428976.00 USD / Year

Elevance Health

Expiration Date

January 09, 2026

Requirements

Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA)
Must possess an active unrestricted medical license to practice medicine or a health profession
Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US
Minimum of 10 years of clinical experience
or any combination of education and experience, which would provide an equivalent background
For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required
Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency

Job Responsibility

Appeal Reviews
Supports clinicians to ensure timely and consistent responses to members and providers
Provides guidance for clinical operational aspects of a program
May conduct peer-to-peer clinical case reviews with attending physicians or other ordering providers to discuss review determinations
Serves as a resource and consultant to other areas of the company
May be required to represent the company to external entities and/or serve on internal and/or external committees
May chair company committees
Interprets medical policies and clinical guidelines
May develop and propose new medical policies based on changes in healthcare
Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes

What we offer

comprehensive benefits package
incentive and recognition programs
equity stock purchase
401k contribution
merit increases
paid holidays
Paid Time Off
incentive bonus programs
medical, dental, vision, short and long term disability benefits
401(k) +match

Fulltime

!

Nephrology Transplant Physician Scientist

Hackensack Meridian Health is seeking a Nephrology Transplant Physician Scientis...

Location

United States , Hackensack

Salary:

198930.00 USD / Year

American Society of Transplantation

Expiration Date

Until further notice

Requirements

MD or equivalent foreign degree
Completion of an Internal Medicine Residency and Transplant Fellowship
Consideration for applicants with strong transplant experience during/after a Nephrology Fellowship
Minimum 3 years in a funded research program
Demonstrated success securing NIH and/or foundation funding
Peer-review experience (manuscripts, grants, editorial boards, or review committees)
Minimum of 15 scientific publications, with majority as first or last author
Board Certified in Internal Medicine
Board Certified or Board Eligible in Nephrology
Eligible for New Jersey Medical License

Job Responsibility

Conduct impactful basic or translational research in transplant/immunology
Pursue grant funding and philanthropic support to sustain laboratory operations
Lead and oversee laboratory processes, research staff, budgeting, and financial management
Establish strategic research goals aligned with the clinical goals of the Division of Organ Transplantation
Hold regular oversight meetings with the Chief Scientific Officer and Director of Transplantation
Develop and implement laboratory policies, procedures, and personnel decisions
Mentor and evaluate lab staff performance
Participate in professional activities, including consulting, editorial work, training, study sections, seminars, and national/international conferences
Evaluate potential living donor and transplant recipient candidates
Provide inpatient and outpatient care for pre- and post-transplant donors and recipients

What we offer

health, dental, vision, paid leave, tuition reimbursement, and retirement benefits

Nurse Practitioner

In accordance with the Vision, Purpose, and Values, and strategic direction of t...

Location

Canada , Gold River

Salary:

74.74 - 82.21 CAD / Hour

Island Health

Expiration Date

Until further notice

Requirements

Registration with BC College of Nurses and Midwives as a practicing NP registrant
Two (2) years of recent, relevant clinical nursing experience
Ability to communicate and collaborate with patients/clients/residents and families about health findings, diagnosis, treatment, self-care and prognosis
Ability to collaborate, consult with and formally refer patients/clients/residents to physicians and other health professionals when appropriate
Ability to critically assess and evaluate health research literature to determine best practices ability to introduce education and evidence based research
Ability to assess and recognize population health trends ability to plan and implement strategies for population based prevention and health promotion
Ability to implement and evaluate planned change
Ability to supervise other and evaluate the care they deliver
Ability to lead a team and work within a team
Ability to self-direct, interact, and adapt effectively with other professionals in complex, dynamic situations

Job Responsibility

Comprehensive assessment of patients/clients/residents including diagnosing diseases, disorders and conditions
Initiates treatment including health care management, therapeutic interventions and prescribes medications
Provides professional guidance to other health professionals and practices autonomously and interdependently within the context of an interdisciplinary health care team
Collaborates with patients/clients/residents and other members of the interdisciplinary team to identify and asses trends and patterns that have implications for patients/clients/residents, families and communities
Develops and implement population and evidence based strategies to improve health and participates in policy-making activities that influence health services and practices
Participates in peer review and self review to evaluate the outcome of services at the patient/client/resident, community and population level

Parttime

Regional Medical Director, Obstetrics

Provide medical leadership and collaborative clinical support to a multi-discipl...

Location

United States

Salary:

210000.00 - 240000.00 USD / Year

Pomelo Care

Expiration Date

Until further notice

Requirements

5+ years practicing as an attending physician
Experience leading collaborative, team-based care
A sense of urgency to improve clinical outcomes coupled with exceptional organization and attention to detail
A growth mindset with the ability to approach process change and ambiguous situations with enthusiasm, creativity, and accountability
Facility using multiple tech platforms, with an eagerness for advising about platform improvements and adapting to new systems
Eager to thrive in a fast-paced, metric-driven environment
Phenomenal interpersonal and communication skills
Medical degree from an accredited US medical school
Successful completion of an accredited US residency program in Obstetrics/Gynecology
Active, unrestricted license to practice in the US and willingness to obtain licenses in all US states

Job Responsibility

Provide collaborative physician supervision and consultation for an experienced team of APPs and RNs
Attend multi-disciplinary team-based care coordination meetings and work with in house clinical specialties to develop holistic individualized care plans
Support the recruitment and training of medical providers
Help drive our pop health programs toward healthier outcomes by partnering closely with your regional Market Operations lead to identify gaps and improvement opportunities
Partner closely with our leadership team to identify and implement interventions to address cross-disciplinary or practice performance improvement needs
Facilitate and lead cross-disciplinary review sessions for episodic events and perform periodic peer review for medical providers

What we offer

Equity
Benefits
Other opportunities at Pomelo Care

Fulltime

Chief Medical Officer

Orlando Health announces an exceptional opportunity for an exemplary physician l...

Location

United States , Orlando

Salary:

Not provided

B.E. Smith

Expiration Date

Until further notice

Requirements

Minimum of 10-15 years of experience as a clinical physician required
Minimum of 5-10 years of physician leadership experience including a strong quality and safety background
MD, DO, MD/PhD or equivalent is required
Board certified in pediatrics or a pediatric sub-specialty
Eligible for licensure in the State of Florida
The CMO requires leadership skills commensurate with a history of leadership roles/responsibilities and an understanding of behavioral and organizational change methodology
Demonstrated experience in executing quality improvement methodologies
and knowledge and/or experience with models for the evaluation of resource use, influencing factors and analysis
Evidence of a strong history of working effectively with a wide range of constituents including all the providers and leadership withing the system
An outstanding listener. Someone who facilitates an open exchange of ideas and fosters an atmosphere of open communication

Job Responsibility

Overseeing and advancing all aspects of quality and patient safety and advancing care delivery capabilities
In collaboration with other leaders, focusing on understanding, addressing and improving operational processes, to improve quality and safety, but also make it easier to deliver care while simultaneously improving access, throughput, and experience (both provider and patient)
Responsible for the hospital staff to ensure evidence-based practice standards, protocols, and direction are in place, and ensures the highest quality and efficiency of patient care in accord with the organization’s mission and values
Acts as the primary liaison between Administration and the hospital staff on a wide variety of matters relevant to developing and sustaining a strong collaborative relationship
Responsible for overseeing and advancing medical staff affairs processes, including privileging, credentialing, peer review, and provider performance (both clinical and behavioral)
Supports and advances physician recruitment, retention, and engagement endeavors along with the educational experience of all trainees

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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Job Description:

Job Responsibility:

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