Specialist / Senior Specialist

Greetings from R1RCM,

We're hiring for Specialist / Senior Specialist.

Job Location : Hyderabad

Qualification : MBBS Physicians or active US Registered Nurse license (NCLEX certification)

Salary : Up-to 25 LPA

Job Summary

The Peer-to-Peer (P2P) Review supports Physician Advisors by reviewing clinically complex cases challenged or denied by payers. The RN/Physician analyzes medical records, applies evidence-based criteria, identifies documentation gaps, and develops concise medical-necessity arguments to prepare physicians for payer peer-to-peer discussions.

Key Responsibilities

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

• MBBS Physicians or active US Registered Nurse license (NCLEX certification)
• 3+ years clinical nursing experience (preferred, not mandate)
• 2+ years 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

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

nterested candidates reach out to :

HR Thushara - 9840681675 / traju4@r1rcm.com