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.