Job Description

Get AI-powered advice on this job and more exclusive features. 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.). Seniority level Seniority level Mid-Senior level Employment type Employment type Contract Job function Job function Health Care Provider Industries Hospitals and Health Care Referrals increase your chances of interviewing at Sierra Solutions by 2x Sign in to set job alerts for “Medical Doctor” roles. Medical Director/Senior Medical Director, Medical Affairs (Remote) Associate Medical Director, Drug Safety and Pharmacovigilance (PV) Senior Director, Medical Information (Remote) Boston, MA $236,000.00-$353,900.00 2 hours ago Senior Medical Director, Pharmacovigilance and Safety Associate Director of Field Medical Training – US Immunology Cambridge, MA $157,500.00-$227,500.00 1 week ago Waltham, MA $278,000.00-$306,000.00 3 weeks ago Director, Field Medical - Gastroenterology, East Boston, MA $191,800.00-$301,400.00 3 days ago Senior Medical Director, Global Medical Safety (Oncology) - Remote US Boston, MA $257,600.00-$404,800.00 2 days ago Waltham, MA $194,000.00-$213,000.00 1 week ago Waltham, MA $182,000.00-$250,000.00 1 week ago Associate Director, Medical Study Operations Associate Director, Audit Management - Medical Device (Remote) Director, Medical Science Liaison - Northeast, South, Central, or West Regions Waltham, MA $233,000.00-$246,000.00 3 weeks ago Senior Medical Director, Clinical Development (MD Required) Staff/Associate Attorney - New York City, NY Cambridge, MA $55,000.00-$65,000.00 2 days ago Medical Director, Gastrointestinal & Inflammation (Remote) Boston, MA $228,200.00-$358,600.00 12 hours ago Sr. Medical Director, Gastrointestinal and Inflammation (Remote) Boston, MA $257,600.00-$404,800.00 12 hours ago Sr. Medical Director, Gastrointestinal and Inflammation (Remote) Boston, MA $257,600.00-$404,800.00 6 days ago Sr. IT Auditor Consultant, Hospital Medical Device IT Controls (BHJOB22048_756) REMOTE Litigation Attorney - Manhattan & Long Island Boston, MA $150,000.00-$175,000.00 1 day ago Physician Specialty Coder (Shared Service Center) We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI. #J-18808-Ljbffr Sierra Solutions

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