Physician Reviewer- REMOTE

Sierra Solutions • Full-time • Remote (New Jersey, United States) • 3d ago

Job Summary

We are seeking a board-certified physician (MD or DO) with clinical experience and knowledge of managed care processes to conduct peer-to-peer reviews, and review appeals and grievances for medical necessity, appropriateness of care, and compliance with health plan policies. The ideal candidate will ensure clinical decisions support evidence-based care and regulatory guidelines.

Primary Responsibilities

Conduct medical necessity reviews for appeals, grievances, and peer-to-peer consultations.
Interpret and apply health plan policies, clinical guidelines, and regulatory requirements.
Communicate directly with requesting providers during peer-to-peer discussions.
Document clinical determinations and rationale clearly and concisely.
Collaborate with internal teams including case managers, utilization review nurses, and compliance staff.
Participate in committee meetings, audits, and quality improvement initiatives as needed.

Education and Experience

MD or DO degree from an accredited medical school.
Current, unrestricted medical license in the United States.
Board certification in a medical specialty.
Minimum of 3-5 years of clinical experience, preferably with experience in managed care or utilization management.
Prior experience with appeals, grievances, or peer review is highly desirable.
Excellent communication and clinical documentation skills.
Knowledge of regulatory standards (CMS, NCQA, URAC, etc.).

Related Jobs

Board Certified Neurologist Physician Advisor, Disability Peer Review

Dane Street, LLC • Contract • Remote (United States) • 4w ago

Utilization Management physician advisor Physician reviewer contract Disability Peer Review

4w ago

Apply

Associate Medical Director, US Medical Affairs

Eisai US • Full-time • Nutley, New Jersey • $177.20k - $232.60k / year • 4w ago

Pharma associate medical director Medical Affairs MD Biotech Neurology AD diagnostic strategy

4w ago

Apply

Global Medical Affairs Leader (GMAL), Bispecific Antibody

Johnson & Johnson Innovative Medicine • Full-time • Raritan, New Jersey, United States • $160k - $276k / year • 2w ago

Pharma Medical Affairs Global Medical Affairs Leader GMAL Bispecific Antibody

2w ago

Apply

Assistant Director, Scientific Medical Affairs

AbbVie • Full-time • Florham Park, New Jersey, US • $137.50k - $261k / year • 3w ago

Pharma Medical Affairs Hematology Oncology MD DO New Jersey Assistant Director Scientific Medical Affairs

3w ago

Apply

Medical Director, Medical Affairs - Hematology

AbbVie • Full-time • Remote (Florham Park, New Jersey, US) • $200.50k - $380.50k / year • 3w ago

Pharma medical director full time Medical Affairs Hematology MD DO Research & Development New Jersey

3w ago

Apply

Head of Research

Day One Biopharmaceuticals • Full-time • Remote (United States) • $430k - $480k / year • 4w ago

Pharma remote MD research Pharmacology Biotechnology chemistry Biochemistry Biology scientist drug developer

4w ago

Apply

Senior Medical Director, Medical Affairs - Bone

Ultragenyx • Full-time • Remote (United States) • $307.60k - $380k / year • 4w ago

Pharma Senior medical director Orthopedics Medical Affairs pediatrics adult oncology

4w ago

Apply

Medical Director - Medical Communications

OPEN Health • Full-time • United States • 4w ago

Pharma medical director Oncology MD Biotech Medical Communications

4w ago

Apply

Medical Monitor / Medical Director (Oncologist)

Caidya • Full-time • Remote (United States) • 4w ago

Pharma medical director Oncology MD CRO Biotechnology Licensed Medical Monitor Oncologist

4w ago

Apply