Peer-to-Peer (P2P) Review RN - R1 RCM

Job Summary:

Peer-to-Peer (P2P) Review RN

Key Responsibilities:

• Review clinical records including ED notes, H&P, progress notes, labs, imaging, vital trends, therapy notes, and medication records.
• Evaluate medical necessities using

  InterQual, MCG, payer-specific criteria, and clinical judgment

  .
• Prepare clear, evidence-based clinical summaries supporting the requested level of care or authorization.
• Identify documentation strengths, gaps, and potential risks before physician review.
• Provide Physician Advisors with organized clinical evidence to support payer discussions.
• Track review status, payer requests, approvals, denials, and follow-up requirements.
• Collaborate with UR nurses, case managers, physicians, and other stakeholders.
• Meet established quality, productivity, compliance, and turnaround requirements.
• Provide feedback on recurring issues and root causes contributing to case determinations.

Required Qualifications:

• Active

  US Registered Nurse license (NCLEX certification), or

• MBBS Physicians.

• 3+ years clinical nursing experience

  (preferred, not mandate)

• 2+ years of recent acute-care Utilization Review experience

  (Good to have)
• Knowledge of Medicare and payer medical-necessity requirements.
• Strong clinical abstraction, analytical, documentation, and communication skills.
• Ability to work independently in a fast-paced environment

Preferred, not mandate:

• CCM or ACM certification

  .
• Experience with concurrent denials, medical-necessity reviews, or P2P case preparation.
• Strong knowledge across multiple clinical specialties.

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Contact Person: Kotha Maheshwari - Lead Associate

Contact Number: 6309134613