Clinical judgment.
Clearly articulated.

Second-level physician review of inpatient versus observation status, short hospital stays, and the level of care supported by the record.

• Severity of illness, treatment intensity, monitoring needs, and the evolving hospital course.
• MCG, InterQual, and payer-specific criteria, with the CMS Two-Midnight framework applied where relevant.
• Physician assessment when screening criteria are not met, with clear medical-necessity reasoning.

Physician assessment of whether the documented findings support reported diagnoses and the associated DRG review question.

• Synthesis of presentation, examination, laboratory and imaging findings, treatment, and clinical course.
• Identification of conflicting or insufficient documentation and clinically significant gaps.
• Collaboration with clinical documentation integrity (CDI), coding, case management, and revenue-cycle teams.
• Clinical validation assessed separately from coding rules and administrative payment requirements.

Representative review topics include acute tubular necrosis, severe malnutrition, acute respiratory failure, and metabolic encephalopathy.

Detailed review of the relationship between hospitalizations, the reason for return, and the care provided between encounters.

• Relatedness and potential preventability, discharge readiness, unresolved problems, and the intervening course.
• Medication reconciliation, follow-up planning, communication, and consultant recommendations.
• Functional needs, available support, caregiver capacity, and discharge destination.
• Clinical opportunities for improvement assessed separately from client-specific readmission payment policies.

Records-based assessment in hospital medicine and nephrology, considering the information available to the treating team at the time.

• Diagnostic reasoning, treatment selection, and the timing of key decisions.
• Monitoring, recognition of deterioration, escalation, and consultant involvement.
• Care coordination, communication, and documentation of clinical reasoning.
• Assessment of potential departures from accepted care, recognizing that an adverse outcome alone does not establish a deficiency.

Experience with internal and external appeals and independent medical-necessity reviews for multiple review organizations.

• Assessment of the submitted record, applicable coverage policy, and relevant medical literature.
• Review of services, procedures, and treatment requests within hospital medicine and nephrology expertise.
• Medical-necessity and experimental or investigational questions within the assigned review scope.
• Clear written rationales addressing the requested determination and the limits of the available evidence.

Independent review experience includes medication authorization, formulary reviews, specialty treatment questions, and medication appeals.

• Clinical indication, prior treatment, applicable plan criteria, and published evidence supporting a request.
• Renal and transplant treatments: IgA nephropathy and cystinosis therapies, finerenone, erythropoiesis-stimulating agents, and immunosuppression.
• Other treatment-review experience includes GLP-1 and GIP/GLP-1 agonists, inhaled insulin, teprotumumab, and zoledronic acid.
• Specialty diagnostic testing includes donor-derived cell-free DNA testing for transplant monitoring.

Examples describe review experience. New assignments are confirmed individually for specialty fit, credentials, and scope.

Experience reviewing nursing-home and skilled-nursing facility appeals, including continued service needs and discharge-related questions.

• Skilled nursing needs and physical and occupational therapy documentation.
• Ambulation, wheelchair mobility, transfers, bed mobility, and assistance requirements.
• Changes in function and the latest assessments in the context of the overall course.
• Discharge support, caregiver availability, and the evidence supporting continued skilled care.

Practical experience in Pennsylvania Medicaid Personal Assistance Services (PAS) reviews.

• Activities of daily living (ADLs), instrumental activities (IADLs), and functional limitations.
• interRAI assessments, time-and-task records, and service-plan documentation.
• Mobility, cognitive and behavioral support needs, safety, and caregiver availability.
• Clinical rationale for the medical necessity of requested assistance and service hours.

Hospital medicine experience and nephrology training support review of medically complex patients and lengthy, multisystem records.

• Acute kidney injury, chronic kidney disease, dialysis, and renal or transplant-related records.
• Fluid, electrolyte, and acid-base disturbances; renal medication safety.
• Clinical chronologies, documentation gaps, evidence synthesis, and focused written reports.

Experience with records-based disability reviews for independent review organizations, without claimant examination or direct patient contact.

• Synthesis of relevant history, findings, and the documented clinical course.
• Focused answers to the assigned medical questions within the review scope.
• Written opinions supported by the supplied record, with attention to documentation limits.

Practical experience completing New York Independent Dispute Resolution (IDR) assignments through review organizations.

• Assessment of the materials and clinical questions assigned within the referring program.
• Written analysis and supporting rationale, with attention to specialty matching and conflict checks.
• Direct engagements depend on the applicable program authority and requirements.