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

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

Appeals Medical Director – Oncology

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

Location

United States of America

Salary:

247840.00 - 446112.00 USD / Year

Elevance Health

Expiration Date

March 13, 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 for 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

!

Appeals Medical Director – Neurology

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

Location

United States of America

Salary:

247840.00 - 446112.00 USD / Year

Elevance Health

Expiration Date

March 13, 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 for 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
medical
dental
vision

Fulltime

!

Appeals Medical Director – Internal Medicine

The Appeals Medical Director for Internal Medicine is responsible for the appeal...

Location

United States of America

Salary:

247840.00 - 446112.00 USD / Year

Elevance Health

Expiration Date

March 13, 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 for 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

!

Lead CRNA

Lead CRNA position at Aurora Medical Center Kenosha, providing clinical and admi...

Location

United States , Pleasant Prairie

Salary:

112.40 - 179.85 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Active RN, and APRN/APRN-FPA/APNP or other APRN license(s) in state(s) of practice
Active national board certification as CRNA by nationally certifying board (NBCRNA)
Active DEA registration prior to hire
If Illinois practice: active Illinois Controlled Substance License 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

Partners locally with physician and operational leaders to optimize clinical practice and supports other clinical activities that advance performance and strategic goals
Participates in local quality improvement, workflow efficiencies and other projects that impact clinical practice
Participates in the recruiting and interviewing process for physicians and APPs
Participates in annual performance reviews (APRs) and scheduled check-ins with new hires in collaboration with operational leaders
Coordinates clinical onboarding and orientation of APPs at local site or within area of support
Champions local engagement and well-being planning and initiatives in partnership with local leaders
Supports bi-directional communication between clinicians and operational leaders
Provides mentorship and professional development of APPs within site or area of support
Collaborates with APP Market Directors, Service Line Councils, MGMCs and other councils related to matters specific to area of practice
Assesses, diagnoses, and determines/alters treatment and management plans appropriate for age, acuity and clinical condition

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

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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