Physician Advisor – (P2P) Medical Reviewer (1099 Contractor) at Clover Health

<p><strong>Position Summary</strong></p> <p>The Physician Advisor<strong> </strong>(1099 Contractor) is a licensed physician responsible for conducting clinical discussions with treating providers regarding utilization management determinations. The physician applies Medicare/CMS requirements, applicable medical necessity criteria, health plan policies, and clinical judgment to determine the appropriate level of care and/or medical necessity of requested services.</p> <p>The role supports timely, consistent, evidence-based utilization management while providing treating physicians an opportunity to discuss relevant clinical information before or following an adverse determination, as applicable.</p> <p><strong>Key Responsibilities</strong></p> <ul> <li> <p>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.</p> </li> <li> <p>Review the member's clinical documentation, utilization management review, applicable criteria, and rationale for the proposed or issued determination before the P2P discussion.</p> </li> <li> <p>Evaluate medical necessity and the appropriate level of care, including inpatient versus observation/outpatient status when applicable.</p> </li> <li> <p>Apply CMS Medicare Advantage requirements, the Two-Midnight benchmark, applicable NCDs/LCDs, MCG or other approved clinical criteria, and health plan policies as appropriate.</p> </li> <li> <p>Discuss the clinical rationale for determinations clearly, professionally, and collegially with treating providers.</p> </li> <li> <p>Consider additional clinical information presented during the P2P and determine whether it changes the medical necessity determination.</p> </li> <li> <p>Approve or overturn a proposed adverse determination when newly presented information supports coverage, within delegated authority and organizational policy.</p> </li> <li> <p>Escalate complex, high-risk, or unclear cases to the appropriate Medical Director or clinical leadership.</p> </li> <li> <p>Document P2P discussions accurately and contemporaneously, including the clinical information discussed, physician participants, outcome, and rationale.</p> </li> <li> <p>Complete P2P requests within established regulatory and organizational turnaround times.</p> </li> <li> <p>Identify recurring clinical, documentation, criteria, or provider-education opportunities and communicate trends to UM leadership.</p> </li> <li> <p>Collaborate with nurses, medical directors, appeals and grievances, provider engagement, and other operational teams as needed.</p> </li> <li> <p>Maintain confidentiality and comply with HIPAA, CMS, accreditation, and organizational requirements.</p> </li> <li> <p>Lead case review discussions on clinical JOCs&nbsp;&nbsp;</p> </li> </ul> <p><strong>Qualifications</strong></p> <ul> <li> <p>MD or DO from an accredited medical school.</p> </li> <li> <p>Current, unrestricted U.S. medical license.</p> </li> <li> <p>Board certification in an appropriate clinical specialty; Internal Medicine, Family Medicine, Emergency Medicine, or another specialty with broad medical experience preferred.</p> </li> <li> <p>Minimum of 5 years of clinical practice experience preferred.</p> </li> <li> <p>Experience with utilization management, medical necessity review, physician advisory services, payer medical review, or hospital case management strongly preferred.</p> </li> <li> <p>Experience with Medicare Advantage and CMS medical necessity/coverage requirements preferred.</p> </li> <li> <p>Familiarity with MCG, InterQual, CMS coverage policies, and the Two-Midnight rule preferred.</p> </li> <li> <p>Strong physician-to-physician communication skills and the ability to manage difficult or disputed clinical discussions professionally.</p> </li> </ul> <p><strong>Core Competencies</strong></p> <ul> <li> <p>Excellent clinical judgment</p> </li> <li> <p>Medical necessity and level-of-care expertise</p> </li> <li> <p>Knowledge of Medicare/CMS requirements</p> </li> <li> <p>Clear and concise physician communication</p> </li> <li> <p>Timely decision-making</p> </li> <li> <p>Accurate clinical documentation</p> </li> <li> <p>Professional conflict resolution</p> </li> <li> <p>Excellent communications skills</p> </li> <li> <p>Consistent application of clinical criteria and policy</p> </li> <li> <p>Ability to distinguish clinical medical-necessity decisions from contractual or administrative issues</p> </li> </ul> <p><strong>Performance Expectations</strong></p> <p>Performance may be evaluated based on timely completion of P2Ps, regulatory turnaround-time compliance, documentation quality, decision accuracy and consistency, inter-rater reliability, provider experience, responsiveness, and adherence to CMS and organizational requirements.</p><div class="content-pay-transparency"><div class="pay-input"><div class="description"><p>Final pay is based on several factors including but not limited to internal equity, market data, and the applicant’s education, work experience, certifications, etc.</p></div><div class="title">A reasonable estimate of the base salary range for this role is:</div><div class="pay-range"><span>$240,000</span><span class="divider">&mdash;</span><span>$300,000 USD</span></div></div></div>