Physician Advisor – (P2P) Medical Reviewer (1099 Contractor)

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.

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