医学顾问 – （P2P）医疗审核员
Physician Advisor – (P2P) Medical Reviewer
**职位概述**
Physician Advisor（1099承包商）是一名持牌医生，负责与治疗提供者就利用管理决定进行临床讨论。该医生应用医疗保险/CMS要求、适用的医疗必要性标准、健康计划政策和临床判断，以确定适当护理级别和/或所请求服务的医疗必要性。
该职位在及时、一致、基于证据的利用管理方面提供支持，并为治疗医生在不利决定前或后（如适用）提供讨论相关临床信息的机会。
**主要职责**
- 与治疗医生和其他合格提供者就住院、门诊、急性后护理及其他授权请求进行定期和临时的面对面讨论。
- 在P2P讨论前，审查会员的临床文档、利用管理审查、适用标准及拟议或已发布的决定的依据。
- 评估医疗必要性和适当的护理级别，包括在适用情况下住院与观察/门诊状态的区分。
- 根据情况应用CMS医疗保险优势要求、两个午夜基准、适用的NCDs/LCDs、MCG或其他批准的临床标准以及健康计划政策。
- 与治疗提供者清晰、专业且友好地讨论决定的临床依据。
- 考虑P2P过程中提供的额外临床信息，并确定是否改变医疗必要性决定。
- 在新信息支持覆盖范围时，在授权范围内和组织政策下批准或推翻拟议的不利决定。
- 将复杂、高风险或不明确的案例上报给合适的医学总监或临床领导。
- 准确且及时地记录P2P讨论，包括讨论的临床信息、医生参与者、结果和依据。
- 在既定监管和组织的处理时间内完成P2P请求。
- 识别重复出现的临床、文档、标准或提供者教育机会，并将趋势传达给利用管理领导。
- 根据需要与护士、医学总监、申诉和投诉、提供者参与及其他运营团队合作。
- 保持保密并遵守HIPAA、CMS、认证和组织政策
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**Position Summary**
The Physician Advisor(1099 Contractor) is a licensed physician responsible for conducting clinical discussions with treating providers regarding utilization management determinations. The physician applies Medicare/CMS requirements, applicable medical necessity criteria, health plan policies, and clinical judgment to determine the appropriate level of care and/or medical necessity of requested services.
The role supports timely, consistent, evidence-based utilization management while providing treating physicians an opportunity to discuss relevant clinical information before or following an adverse determination, as applicable.
**Key Responsibilities**
- Conduct scheduled and ad hoc peer-to-peer discussions with treating physicians and other qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests.
- Review the member's clinical documentation, utilization management review, applicable criteria, and rationale for the proposed or issued determination before the P2P discussion.
- Evaluate medical necessity and the appropriate level of care, including inpatient versus observation/outpatient status when applicable.
- Apply CMS Medicare Advantage requirements, the Two-Midnight benchmark, applicable NCDs/LCDs, MCG or other approved clinical criteria, and health plan policies as appropriate.
- Discuss the clinical rationale for determinations clearly, professionally, and collegially with treating providers.
- Consider additional clinical information presented during the P2P and determine whether it changes the medical necessity determination.
- Approve or overturn a proposed adverse determination when newly presented information supports coverage, within delegated authority and organizational policy.
- Escalate complex, high-risk, or unclear cases to the appropriate Medical Director or clinical leadership.
- Document P2P discussions accurately and contemporaneously, including the clinical information discussed, physician participants, outcome, and rationale.
- Complete P2P requests within established regulatory and organizational turnaround times.
- Identify recurring clinical, documentation, criteria, or provider-education opportunities and communicate trends to UM leadership.
- Collaborate with nurses, medical directors, appeals and grievances, provider engagement, and other operational teams as needed.
- Maintain confidentiality and comply with HIPAA, CMS, accreditation, and organizational requirements.
- Lead case review discussions on clinical JOCs
**Qualifications**
- MD or DO from an accredited medical school.
- Current, unrestricted U.S. medical license.
- Board certification in an appropriate clinical specialty; Internal Medicine, Family Medicine, Emergency Medicine, or another specialty with broad medical experience preferred.
- Minimum of 5 years of clinical practice experience preferred.
- Experience with utilization management, medical necessity review, physician advisory services, payer medical review, or hospital case management strongly preferred.
- Experience with Medicare Advantage and CMS medical necessity/coverage requirements preferred.
- Familiarity with MCG, InterQual, CMS coverage policies, and the Two-Midnight rule preferred.
- Strong physician-to-physician communication skills and the ability to manage difficult or disputed clinical discussions professionally.
**Core Competencies**
- Excellent clinical judgment
- Medical necessity and level-of-care expertise
- Knowledge of Medicare/CMS requirements
- Clear and concise physician communication
- Timely decision-making
- Accurate clinical documentation
- Professional conflict resolution
- Excellent communications skills
- Consistent application of clinical criteria and policy
- Ability to distinguish clinical medical-necessity decisions from contractual or administrative issues
**Performance Expectations**
Performance may be evaluated based on timely completion of P2Ps, regulatory turnaround-time compliance, documentation quality, decision accuracy and consistency, inter-rater reliability, provider experience, responsiveness, and adherence to CMS and organizational requirements.
Final pay is based on several factors including but not limited to internal equity, market data, and the applicant’s education, work experience, certifications, etc.
A reasonable estimate of the base salary range for this role is:
$240,000—$300,000 USD