Remote Physician Advisor (1099) Medical Utilization Reviewer

Clover Health; United States; Remote; USD 240,000 - 300,000; Full time

Benefits offered by this job

Reasonable accommodations during the申请

Job summary

Clover Health is seeking a Physician Advisor (1099 Contractor) who is licensed in the United States to lead utilization management discussions with treating providers. The role applies Medicare/CMS requirements, clinical criteria, and plan policies to determine appropriate level of care and medical necessity.

The Physician Advisor will review documentation, participate in peer-to-peer discussions, and escalate or approve determinations while ensuring timely, evidence-based decisions compliant

Qualifications

• 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.

Responsibilities

• 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 the member's clinical documentation, utilization management review, applicable criteria, and rationale for the proposed or issued determination before the P2P discussion.
• Evaluate medical necessity and the appropriate level of care, including inpatient versus observation/outpatient status when applicable.
• Apply CMS Medicare Advantage requirements, the Two-Midnight benchmark, applicable NCDs/LCDs, MCG or other approved clinical criteria, and health plan policies as appropriate.
• Discuss the clinical rationale for determinations clearly, professionally, and collegially with treating providers.
• Approve or overturn a proposed adverse determination when newly presented information supports coverage, within delegated authority and organizational policy.
• Document P2P discussions accurately and contemporaneously, including the clinical information discussed, physician participants, outcome, and rationale.

Skills

MD/DO holder

US Medical License

Board Certification

Utilization management

CMS Medicare knowledge

Clinical judgment

Physician-to-physician communication

Education

MD or DO degree

Job description

Clover Health is seeking a Physician Advisor (1099 Contractor) who is licensed in the United States to lead utilization management discussions with treating providers. The role applies Medicare/CMS requirements, clinical criteria, and plan policies to determine appropriate level of care and medical necessity.

The Physician Advisor will review documentation, participate in peer-to-peer discussions, and escalate or approve determinations while ensuring timely, evidence-based decisions compliant