Physician Advisor – (P2P) Medical Reviewer
C
Clover HealthHealthcare
Remote - USAContractSenior
Salary240,000 - 300,000 USD per year
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Job Details
- Experience
- Minimum of 5 years of clinical practice experience preferred.
Requirements
- MD or DO degree from an accredited medical school.
- Current, unrestricted U.S. medical license.
- Board certification in an appropriate clinical specialty (Internal Medicine, Family Medicine, or Emergency Medicine preferred).
- Minimum of 5 years of clinical practice experience preferred.
- Experience with utilization management, medical necessity review, or physician advisory services strongly preferred.
- Experience with Medicare Advantage and CMS requirements preferred.
- Familiarity with MCG, InterQual, and the Two-Midnight rule preferred.
- Ability to manage difficult or disputed clinical discussions professionally.
Responsibilities
- Conduct scheduled and ad hoc peer-to-peer discussions with treating physicians regarding authorization requests.
- Review clinical documentation, medical necessity criteria, and rationale for proposed determinations.
- Evaluate appropriate level of care, including inpatient versus observation status.
- Apply CMS, NCDs/LCDs, and MCG clinical criteria to support evidence-based decisions.
- Discuss clinical rationale clearly and professionally with treating providers.
- Approve or overturn adverse determinations based on newly presented clinical information.
- Document all P2P discussions accurately and maintain regulatory turnaround times.
- Collaborate with internal medical directors, nursing, and appeals teams.
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