Job Summary:

The Peer-to-Peer (P2P) Review RN supports Physician Advisors by reviewing clinically complex cases challenged or denied by payers. The RN 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 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.
- Robust 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.

Know someone who fits the criteria? Share this post with them. Contact Person: Kotha Maheshwari - Lead Associate

Contact Number: (phone hidden)

📌 Peer-to-PeerP) Review RNRCM (Hyderabad)
🏢 R1 RCM
📍 Hyderabad