Healthfirst · 2 months ago
Physician Peer Reviewer – NY Licensed (Internal or Family Medicine B/C)
United States
Full-time
Remote
Mid, Senior Level
$123K/yr - $188K/yrHealthfirst is a healthcare organization, and they are seeking a Medical Peer Reviewer to play a critical role in consulting on medical necessity in the context of utilization management. This role involves assessing authorization requests, rendering clinical judgments, and collaborating with various departments to ensure compliance with regulations.
Commercial InsuranceHealth CareHealth InsuranceInsurance
Responsibilities
The Medical Peer Reviewer will assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations
The Medical Peer Reviewer will render determinations in the format and within timeframes to follow Regulatory and Operational policies
The Medical Peer Reviewer will:
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
Responsibilities may be adjusted based on changing needs of the organization
Each Medical Reviewer will cover one legal holiday /year and will be compensated Holiday pay and straight hours worked
The Medical Reviewer is eligible for Paid Time Off (PTO) and is required to plan and schedule time off with their direct supervisor following the Company policy
Each Medical Reviewer is required to be primary coverage one weekend a month
Each Medical Reviewer is required to be available as back up, if needed, one weekend a month
Qualification
Required
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
Preferred
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
Benefits
Medical, dental and vision coverage
Incentive and recognition programs
Life insurance
401k contributions
Company
Healthfirst
Healthfirst is a health insurer providing medical, business, and health insurance services.
Founded in 1993
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Pat Wang
President and CEO
Recent News
2025-10-10
Crain's New York Business
2025-09-23
2025-08-21
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