Physician Advisor: Utilization Management & P2P Lead

Clover Health; Jersey City (NJ); On-site; USD 240,000 - 300,000; Full time

Benefits offered by this job

Remote work not specified

Job summary

Clover Health seeks a Physician Advisor (1099 Contractor) to conduct clinical discussions with treating providers regarding utilization management determinations. You will apply Medicare/CMS requirements, medical necessity criteria, and health plan policies to determine appropriate level of care and/or medical necessity of services.

Responsibilities include peer-to-peer discussions, reviewing documentation, and documenting outcomes with clear rationale.

Qualifications

• MD or DO with valid US medical license.
• Board certification in internal medicine or related field preferred.
• Experience in utilization management and payer reviews preferred.

Responsibilities

• Conduct peer-to-peer discussions with treating physicians on authorization requests.
• Review clinical docs and rationale before P2P discussion.
• Evaluate medical necessity and level of care (inpatient vs observation/outpatient).
• Apply CMS Medicare Advantage requirements, MCG/InterQual criteria, and policies.
• Document discussions accurately and contemporaneously.

Skills

Medical communication

Decision-making

CMS Medicare knowledge

Utilization management experience

Payer medical review

Education

MD or DO from an accredited medical school

Current U.S. medical license

Job description

Clover Health seeks a Physician Advisor (1099 Contractor) to conduct clinical discussions with treating providers regarding utilization management determinations. You will apply Medicare/CMS requirements, medical necessity criteria, and health plan policies to determine appropriate level of care and/or medical necessity of services.

Responsibilities include peer-to-peer discussions, reviewing documentation, and documenting outcomes with clear rationale.