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

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

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

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

Rn-prior authorization/referral procedure and insurance coordinator

RN, Prior Authorization/Referral/Procedure and Insurance Coordinator functions a...

Location

United States , Des Moines

Salary:

Not provided

IntelyCare

Expiration Date

Until further notice

Requirements

Graduate of an accredited school of nursing or IA Board of Nursing approved nursing program
Current licensure in good standing to practice as a Registered Nurse in Iowa
Valid driver's license
Basic Life Support (BLS) ceritification or obtain certification within three months from date of hire
Mandatory Report Certification
Two (2) years of RN experience

Job Responsibility

Coordinates and develops ongoing patient care, including appointments, communication, and instruction
Function as a clinician, educator and resource for patients within their specialty of care
Assist provider and clinical staff with patient prep for examinations, treatments, and minor clinic procedures
Delivers high quality care utilizing the nursing process while demonstrating knowledge and clinical skills in accordance with established policies, procedures, and standards of care throughout the clinic and across the health care continuum
Maintain flexibility by demonstrating an ability and willingness to perform a variety of duties and accept changes or additions to assignments
Thoroughly understand testing (lab and procedures) values and relationship to patient status with accountability to take next steps, as appropriate to scope and licensure
Utilize critical thinking in making independent judgements and maintains responsibility and accountability for the knowledge of conditions of assigned patients
Builds and maintains positive working relationships with patients, physicians, and all others
Perform other duties as requested by Manager of Oncology Services to facilitate the smooth and effective operations of the hosp/clinics
Maintains knowledge of clinical protocols to facilitate timely and complete work up of patients

What we offer

paid time off
parental leave
401K matching
employee recognition program
Dental and health insurance
paid holidays
short and long-term disability
pet insurance
Early access to earned wages with Daily Pay
tuition reimbursement

Fulltime

Cancer Registrar

Responsible for collecting, abstracting, coding, analyzing, reporting and follow...

Location

United States

Salary:

26.55 - 39.85 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Associate degree in health information management or related field (or if working in Cancer Registry, enrollment in Associate degree program and ready to start practicum)
Typically requires 1 year of experience in data collection that includes experiences in coding/abstracting and clinical documentation
Knowledge of medical terminology, anatomy and physiology and pathophysiology
Knowledge of computer applications, computer function and basic statistical methods
Ability to follow detailed coding instructions and specifications with minimal supervision
Ability to work independently with a high degree of accuracy and attention to detail
Ability to communicate well orally and in written format
Ability to travel as needed with exposure to road and weather conditions
Ability to spend extended periods of time (75% of the workday) in sedentary work
Ability to operates all equipment necessary to perform the job

Job Responsibility

Performs review of complex clinical records to secure data for inclusion into the formal longitudinal registries required by the organization
Uses appropriate classification and coding systems via computerized software, within the time frames required by local, state and national mandates
Abstracts high integrity information from the internal medical record and conducts concurrent and or retrospective review of external medical records in order to facilitate complete analysis, monitoring and reporting of quality data
Performs interoperability and reliability testing and utilizes various data quality monitoring techniques to reconcile and validate information according to registry and internal data quality standards and data dictionaries
Completes the process for timely submission of data at appropriate intervals to the various advanced and complex disease/procedure specific specialty databases and other registries as required for compliance with membership and professional standards
Coordinates multi-disciplinary weekly case conferences, preparing notices, summations and submits all required Continuing Professional Development department post-conference documentation for CME
Develops, performs, and evaluates quality improvement activities for the registries ensuring a percent of abstracted data is physician and peer reviewed on an annual basis
Performs follow-up of appropriate registry patients over their lifetime as required, maintaining the accuracy and integrity of the data for use in end-results, financial, market, research and quality reporting
Establishes and maintains effective working relationships with physicians and care management staff working together to compile registry data into meaningful reports/displays and promotes the use and visibility of the information collected
Prepares and assists with studies for publication, audits, and annual reports in a timely fashion

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

New

PA or NP Emergency Medicine

Location

United States , Kenosha

Salary:

59.00 - 88.50 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Active PA license(s) in state(s) of practice
Active PA national board certification from National Commission on Certification of Physician Assistants
Active DEA registration prior to hire
If Illinois practice: active Illinois Controlled Substance License prior to hire
Active BLS and/or ACLS, PALS, NRP as required by clinical practice prior to or within 6 months of hire
Bachelor’s Degree in Physician Assistant
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

Assesses, diagnoses, and determines/alters treatment and management plans appropriate for age, acuity and clinical condition
Manages conditions based on clinical indication, evidence-based care, cost effectiveness, and assessment of risks/benefits and alternatives
Provides health promotion, disease prevention and disease management counseling and education of patients and families
Manages patients as part of an interdisciplinary team and within scope of practice
Maintains accurate, complete, concise, and timely documentation in the electronic medical record
Facilitates consistent, coordinated care and clear communication among all members of the healthcare team and/or health or community agencies
Performs office or hospital procedures in accordance with specialty practice, competency and granted privileges
Participates in quality, safety, and peer review initiatives/performance activities, organizational and/or departmental meetings and committees, peer review, and workgroups
Participates in education and/or onboarding of new team members, students, and other health care professionals
Seeks experiences to maintain and develop clinical and professional skills and advance the profession

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
Premium pay such as shift, on call, and more
Incentive pay for select positions
Opportunity for annual increases based on performance

Parttime

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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