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