Clover Health - Physician Advisor – (P2P) Medical Reviewer (1099 Contractor)
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. • Core Competencies • Core Competencies • Excellent clinical judgment • Medical necessity and level-of-care expertise • Clear and concise physician communication • 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 • Performance Expectations • 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. • 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. • A reasonable estimate of the base salary range for this role is: • $240,000—$300,000 USD
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. • Discuss the clinical rationale for determinations clearly, professionally, and collegially with treating providers. • Consider additional clinical information presented during the P2P and determine whether it changes the medical necessity determination. • Approve or overturn a proposed adverse determination when newly presented information supports coverage, within delegated authority and organizational policy. • Escalate complex, high-risk, or unclear cases to the appropriate Medical Director or clinical leadership. • Document P2P discussions accurately and contemporaneously, including the clinical information discussed, physician participants, outcome, and rationale. • Complete P2P requests within established 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 as needed. • Maintain confidentiality and comply with HIPAA, CMS, accreditation, and organizational requirements. • Lead case review discussions on clinical JOCs
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