Physician Advisor – Medical Reviewer, 1099 Contractor

Job not on LinkedIn

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $240k - $300k / year

⏳ Contract/Temporary

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

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Clover Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

🏥 Healthcare

🛡️ Insurance

🤖 Artificial Intelligence

Healthcare • Insurance • Artificial Intelligence

Clover Health is a healthcare technology company helping members live their healthiest lives with our Medicare Advantage plans. Focused on seniors who have historically lacked access to affordable and high-quality healthcare, Clover aims to provide care sustainably by improving medical outcomes while simultaneously lowering avoidable costs. They leverage a proprietary software platform, the Clover Assistant, to aggregate patient data and offer real-time recommendations to healthcare providers. Their services include affordable Medicare Advantage plans, a home care program, and they manage care for Medicare Advantage members across several U. S. states.

📋 Description

• Conduct scheduled and ad hoc peer-to-peer discussions with treating physicians and other qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests • Review members' clinical documentation, utilization management review, applicable criteria, and rationale for proposed or issued determinations • Evaluate medical necessity and the appropriate level of care, including inpatient versus observation/outpatient status • Apply CMS Medicare Advantage requirements, the Two-Midnight benchmark, applicable NCDs/LCDs, MCG or other approved clinical criteria, and health plan policies • Discuss clinical rationale for determinations with treating providers • Consider additional clinical information and determine whether it changes the medical necessity determination • Approve or overturn proposed adverse determinations when supported by new information, within delegated authority and organizational policy • Escalate complex, high-risk, or unclear cases to Medical Directors or clinical leadership • Document P2P discussions accurately and contemporaneously • Complete P2P requests within regulatory and organizational turnaround times • Identify recurring clinical, documentation, criteria, or provider-education opportunities and communicate trends to UM leadership • Collaborate with nurses, medical directors, appeals and grievances, provider engagement, and other operational teams • Maintain confidentiality and comply with HIPAA, CMS, accreditation, and organizational requirements • Lead case review discussions on clinical JOCs

🎯 Requirements

• MD or DO from an accredited medical school • Current, unrestricted U.S. medical license • Board certification in an appropriate clinical specialty; Internal Medicine, Family Medicine, Emergency Medicine, or another specialty with broad medical experience preferred • Minimum of 5 years of clinical practice experience preferred • Experience with utilization management, medical necessity review, physician advisory services, payer medical review, or hospital case management strongly preferred • Experience with Medicare Advantage and CMS medical necessity/coverage requirements preferred • Familiarity with MCG, InterQual, CMS coverage policies, and the Two-Midnight rule preferred • Strong physician-to-physician communication skills and the ability to manage difficult or disputed clinical discussions professionally • Excellent clinical judgment • Medical necessity and level-of-care expertise • Knowledge of Medicare/CMS requirements • Timely decision-making • Accurate clinical documentation • Professional conflict resolution • Consistent application of clinical criteria and policy • Ability to distinguish clinical medical-necessity decisions from contractual or administrative issues